Bariatric Care

Question 1

What is overweight and obesity defined as

Answer 1

abnormal or excessive fat accumulation that may impair health.

Question 2

What is a bariatric person

Answer 2

an individual of any age (child to adult) who has limitations in health and social care due to physical size, health, mobility and environmental access.

Question 3

What is BMI defined as

Answer 3

as weight in kilograms divided by the square of the height in meters.
BMI provides the most useful population-level measure as it is inexpensive, easy to use, the same for both sexes and for all ages of adults.

Question 4

What are limitations of BMI

Answer 4

Does not assess body fat distribution, because it is a measure of excess weight rather than excess body fat.
Does not account for factors such as age, sex, ethnicity, and muscle mass.

Question 5

What is the fundamental cause of obesity

Answer 5

energy imbalance between calories consumed and calories expended.

Question 6

What factors play a significant role in obesity

Answer 6

genetics, socioeconomic status, environment and individual decisions

Question 7

What are contributing factors to obesity

Answer 7

Underlying health problems e.g. hypothyroidism in Down’s syndrome and eating issues such as Prader-Willi syndrome
A lack of energy
Difficulty with chewing or swallowing food or its taste or texture
Medications that can contribute to weight gain and changes to appetite e.g. steroid medication
Physical limitations that can reduce a person’s ability to exercise pain on movement (e.g. in cerebral palsy, rheumatoid arthritis
Lifestyle Factors: A lack of healthy food choices; Accessible environments that enable exercise; Resources and appropriate social support systems

Question 8

Is obesity a disability

Answer 8

not by equality act but conditions associated with obesity may lead to disability
Failure to provide suitable safe facilities for bariatric patients has the potential to breach the Equality Act (2010)

Question 9

What is expected from dental professionals regarding adjustment

Answer 9

Those with disabilities should have the same access to health care as anyone else and it is the responsibility of health care professionals to make reasonable adjustments to aid universal access to our services.

Question 10

What is the role of the dental team regarding obesity

Answer 10

Identify oral health issues associated with the bariatric patient.

Signpost patients to appropriate services e.g Weight management.

Be aware of comorbidities or predisposition to dental disease.

Appropriate referral onto Secondary and Tertiary care.

May have to provide emergency care prior to onward referral.

Raise concerns with patient, parents or carers of vulnerable adults and children.

Question 11

What should be considered prior to the appointment

Answer 11

Ensure your venue has appropriate facilities for patient care.
This may involve telephoning the patient/referrer/carer prior to initial visit querying: Patient Weight or BMI, Mobility e.g. do they use a wheelchair? Manual or motorised?

Question 12

What should be considered regarding travel

Answer 12

Is the patient taking private transport e.g car / taxi? Parking should be available as close to the venue as possible.
Ambulance transport - will only take patients to Hospitals

Question 13

What should be considered regarding accessibility

Answer 13

Waiting room with suitable high weight bearing armless chair.
Adequate door widths
Toilet facilities accessible
Is the practice accessible via lift or stairs

Emergency Evacuation procedures

Under no circumstances should staff attempt to break the fall of an obese patient

Question 14

What should be considered regarding the timing

Answer 14

May require longer appointment times due to reduced mobility
Extra weight around the face can obstruct the access to the mouth

Question 15

What should be considered regarding safety

Answer 15

Specialist equipment may mean patients need referral tospecialist clinics or hospitals
Wider cuff blood pressure monitors.(e.g. “thigh cuff”); Longer IM needles are needed.
May be unable to get patient rapidly into supine/recovery position or physically move patient.
Airway management may be more difficult.
Resuscitation – identification of landmarks for chest compressions may be difficult

Question 16

What should be considered regarding the chair

Answer 16

If the patient does not know their weight and is perceived to exceed 22 stone/140kg an accurate weight must be obtained through weighing the patient.
Unfortunately most standard weighing scales only weigh up to 22 stone.

Question 17

What are people who carry weight in upper body and chest at risk of

Answer 17

hypoxaemia when lying flat.

In extreme circumstances some may present with obesity hypoventilation syndrome - this is a result of chronic hypoventilation due to the prevention of full expansion of the lungs.

Question 18

What are comorbidies of obesity

Answer 18

Hypertension and CVA. 
Diabetes
Sleep apnoea (may use a CPAP machine) 
Dyspnoea 
Gastro oesophageal reflux disease (GORD) 
Osteoarthritis
Depression/anxiety 
Liver and gallbladder disease 
Skin conditions such as cellulitis and intertrigo

Question 19

Why does obesity make tx difficult

Answer 19

Loss of anatomical landmarks is possible. There are access problems with large cheeks, tongue etc.

ID blocks may be difficult. Alternative techniques may need to be considered such as the Gow-Gates or intraligamentary techniques.

May have to be treated semi-supine or sitting upright – practitioners need to be careful with their posture.

Beware operator musculo-skeletal problems when working in a less than ideal position.

Question 20

How does obesity impact radiographs

Answer 20

Intra-oral radiography can be more challenging due to increased soft tissues.
OPT can be difficult or even impossible if the machine is unable to accommodate the patient’s size.
Long procedures can lead to acute leg oedema, cellulitis, Compartment Syndrome and pressure sores.
Coagulation abnormalities may occur (e.g. due to non-alcoholic fatty liver disease)
Excessive fat in the tissues may also affect pharmacological absorption of a drug

Question 21

What is compartment syndrome

Answer 21

painfull, bleeding and swelling within enclosed muscles increasing pressure, restricts the blood flow and damages nerves/muscles

Question 22

What are dental implications of periodontitis

Answer 22

Obesity does not appear to play a negative role in the treatment outcome of non-surgical periodontal therapy.
Diabetic patients have a high associated risk of periodontal disease.
Be aware of the complexity of obesity and be able to discussthe importance of maintaining healthy body weight and performing good oral hygiene procedures.

Question 23

What are dental implications of obesity

Answer 23

caries
wound healing
tooth wear

Question 24

What is the impact of obesity on caries

Answer 24

Bariatric patients may have a higher caries rate than general population as causations are interrelated (diet high in processed sugars).

Question 25

What is the impact of obesity on wound healing

Answer 25

Extractions, Surgical Periodontal Treatment, Biopsies;

Bariatric patients are more likely to have reduced immune function leading to delayed wound healing.

Question 26

What is the impact of tooth wear on wound healing

Answer 26

Erosive tooth wear is more likely - increased prevalence of GORD in bariatric persons.
Increased incidence of oesophageal reflux, in particular in those having gastric banding, causing acid erosion.

Question 27

What is domiciliary care

Answer 27

Rarely the first line option
.
Useful when patients too large and/or too anxious to leave their home.

A domiciliary visit may also be useful for initial assessment, then arranging further review in the clinic.

Treatment is usually restricted to inexpensive, short procedures which carry little risk such as examinations.

Question 28

What should be done for emergency appointments

Answer 28

Provide emergency relief of pain treatment only, weighing up risks and benefits.
Patient and staff health and safety should not be compromised.
If a patient is unsuitable for your dental chair consider treating in their own wheelchair or in a bariatric wheelchair.
Future appointments should be arranged in clinic with suitable facilities

Question 29

Why is there a link between learning disability and obesity

Answer 29

Those with learning disabilities can experience weight gain, especially those living independently unless they have careful diet control

Anti-psychotic medications, such as clozapine and olanzapine, predispose patients to weight gain

Question 30

What are options for obese patients with dental anxiety

Answer 30

inhalation sedation
intravenous sedation
GA

Question 31

Discuss inhalation sedation for obese px

Answer 31

No specific contraindications however special care must be taken to ensure good safe airway management.
This may be the most appropriate form of sedation for these patients.

Question 32

Discuss intravenous sedation for obese px

Answer 32

Obese adults are at risk of sleep apnoea - a contraindication to dental sedation in a primary care setting.
Bariatric adults are not suitable for conscious sedation in a standard dental clinic due to difficulty placing cannula.
Bariatric adults may have compromised airways which require specialist teams to manage in an emergency with the appropriate resuscitation equipment.

Question 33

What is risk fo GA for obese

Answer 33

Obese patients are twice as likely to develop serious airway problems during a GA than the non-obese.

Question 34

How should you communicate with bariatric px

Answer 34

Explain any changes to treatment plan/venue as a result of their weight sensitively but honestly.
Patients may be quite resistant to being referred elsewhere - they may feel ashamed or upset.
They may have experienced discrimination in many services because of their size.
Highlight the importance of you and your patient’s safety and also the need for the best possible care in the best possible setting. Keep reasons technical and not personal.
Making too much of an issue regarding a patient’s weight may only serve to make them more embarrassed and anxious when attending the dentist. This may make them less likely to re-attend
Arrange onward referral as required and keep the patient informed

Question 35

What is bariatric surgery benefits

Answer 35

Results in greater improvement in weight loss outcomes, improved control of comorbidities and significant improvement in self-esteem.

Question 36

What are negative consequences of bariatric surgery

Answer 36

Negative consequences e.g. nutritional deficiencies,“dumping” syndrome and eating disorders, such as anorexia, bulimia and compulsive eating.
Correlationwith oral problems, such as periodontal disease, increase in dental caries, hyposalivation, ulcers, dentine sensitivity and halitosis.
Following surgery patients are advised to divide food intake into 4-6 meals throughout the day, chewing slowly.
Higher frequency and prolonged meal times = increase risk of caries as sugary items are ingested.
At increased risk of dental erosion due to the common side effect of reflux and vomiting

Question 37

What are clear messages dentist can give for bariatric surgery

Answer 37

Ingestion of a healthy, balanced diet
Adequate oral hygiene.
Stimulate salivary flow to avoid dry mouth
Chew gum without sugar, but only two month after surgery
Use a tongue scraper;
Take care to avoid tooth wear
Drink soft drinks or fruit juices through a straw to minimize contact with the teeth
Never brush the teeth after episodes of vomiting or reflux
Provide topical fluoride varnish and OHI as required