bariatric care Flashcards
overweight and obese
defined as abnormal or excessive fat accumulation that may impair health.
bariatric person
individual of any age (child to adult) who has limitations in health and social care due to physical size, health, mobility and environmental access.
obesity deaths
responsible for 3.4 million deaths, has nearly tripled worldwide, contrary to other major global risks (tobacco)
projected increase in obese adults in UK by 2030
11 million
scottish health survey 2018
65% of adults were overweight;
- 28% who were obese;
68% of men and 63% of women were overweight or obese;
Mental wellbeing was lowest among those within the morbidly obese BMI range;
The annual cost of treating conditions associated ranged from £363 million to £600 million
BMI overweight
World Health Organisation defines overweight as a BMI ≥25 kg/m squared
BMI Obese
World Health Organisation defines overweight as a BMI ≥30 kg/m squared
BMI
defined 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.
limitation of BMI
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
BMI use
most useful population-level measure as it is inexpensive, easy to use, the same for both sexes and for all ages of adults.
contributing factors to obesity
Underlying health problems
- e.g. hypothyroidism in Down’s syndrome and eating issues such as Prader-Willi syndrome (cause excess hunger)
Lack of energy
Difficulty with chewing or swallowing food or its taste or text
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)
Multiple factors influence including genetics, socioeconomic status, environment and individual decisions play a significant role.
fundamental cause of obesity and overweight is
an energy imbalance between calories consumed and calories expended.
Obesity is a complex, multifactorial chronic disease that is strongly associated with multiple comorbidities.
- undernutrition and obesity co-existing.
lifestyle factors which contribute to obesity
A lack of healthy food choices;
Accessible environments that enable exercise;
Resources and appropriate social support systems
equality act 2010 and obesity
Does not classify obesity as a disability.
- However, conditions associated with obesity may lead to disability.
E.g. wheelchair needed for mobility
Failure to provide suitable safe facilities for bariatric patients has the potential to breach the Equality Act (2010)
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
- E.g. physical adjustments (alterations to buildings in the form of wheelchair ramps or tactile signage) attitude adjustments (through policies, procedures and staff training, to ensure that services are as accessible for all patients.)
role of dental team in bariatric care
Increasing prevalence of obesity within the general population = likely increase in bariatric adults accessing dental services
- Identify oral health issues associated with the bariatric patient.
- Signpost patients to appropriate services e.g Weight management. Usually via GP
- 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.
Obese patients may present significant medical, logistical and surgical challenges. Nevertheless the majority are healthy for dental tx
dental team things to do prior to bariatric appointment
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?
NAFLD
non alcoholic fatty liver disease
things to consider for travel of bariatric pt
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
accessibility consideration for bariatric pt
Waiting room with suitable high weight bearing armless chair. (right)
Adequate door widths
Toilet facilities accessible (wheelchair)
Is the practice accessible via lift or stairs (reinforced lift/stairs/walkway)?
Emergency Evacuation procedures (lift out of boundaries)
Under no circumstances should staff attempt to break the fall of an obese patient
timing considerations for bariatric pts
May require longer appointment times due to reduced mobility
Extra weight around the face can obstruct the access to the mouth
safety consideration for bariatric pts
Specialist equipment may mean patients need referral to specialist 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
things to consider when bariatric pt in the chair
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.
People who carry weight on their chest and upper body are at risk of hypoxaemia when lying flat.
- In extreme circumstances some obese patients may present with obesity hypoventilation syndrome, a result of chronic hypoventilation due to the excess weight preventing full expansion of the lungs.
how to ask pt weight without intruding
Make inclusive in medical history – height and weight
- part of standard questions
co - morbidities of obesity
Hypertension and Cerebrovascular accident (CVA)
- (Do they suffer from angina? At rest or on exertion?)
Diabetes
Sleep apnoea
Dyspnoea
Gastro oesophageal reflux disease (GORD)
- Especially after bariatric surgery
Osteoarthritis
Depression/anxiety
- Often directly related to embarrassment/shame due to their size
Liver and gallbladder disease
Skin conditions e.g. cellulitis and intertrigo
intertigo
Inflammation within excessive body fold
sleep apnoea
- breathing stops and starts in sleep
- gasping or choking
- May use a CPAP machine (Continuous positive airway pressure)
dyspnoea
- Shortness of breath SOB
- Are they able to walk comfortably without getting breathless
treatment of bariatric pt obstacles
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.
Consider use of a ‘Lax’ tongue retractor if a dental mirror is insufficient for soft tissue retraction (top; or lolly pop sticks retractors)
May have to be treated semi-supine or sitting upright
- Beware operator musculo-skeletal problems when working in a less than ideal position.
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)
- Check bloods before extractions or potentially bleeding procedures
Excessive fat in the tissues may also affect pharmacological absorption of a drug
compartment syndrome
painful, bleeding and swelling within enclosed muscles increasing pressure, restricts the blood flow and damages nerves/muscles
dental implications of bariatric pt (4)
periodontitis
caries
wound healing
tooth wear
periodontitis impact from bariatric patient
The relationship between obesity and periodontal disease has been acknowledged as associative but there is no evidence of a causal relationship.
Obesity does not appear to play a negative role in the treatment outcome of non-surgical periodontal therapy.
Diabetic pt - higher associated risk of periodontal disease. (linked to obesity)
- Be aware of the complexity of obesity and be able to discuss the importance of maintaining healthy body weight and performing good oral hygiene ne procedures.
caries impact from bariatric pt
Bariatric patients may have a higher caries rate than general population as causations are interrelated (diet high in processed sugars).
wound healing impact from bariatric pt
Extractions, Surgical Periodontal Treatment, Biopsies;
- Bariatric patients are more likely to have reduced immune function leading to delayed wound healing.
tooth wear impact from bariatric patient
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.
how to treat Mr M
46 year old male from Glasgow.
- Has had toothache for the last few days keeping him awake at night.
- Not seen dentist in many years “never fit the last chair which was embarrassing” and led him to never go back for treatment.
“Teeth are a mess”
MH: Type 2 Diabetic, Asthmatic, NAFLD non-alcohol fatty liver disease
BMI of 37 (WHO obesity class II)
Occasionally mobilises in wheelchair when out
Full dental and medical histories
Dental examination in patients own wheelchair
Special Investigations: radiograph of painful tooth
- finds unrestorable subgingival caries and periapical pathology relating to lower right first permanent molar
Treatment:
- Do nothing – nope, in pain
- Extraction - Positioning of yourself and patient, do you feel confident in your IDB placement, should you take bloods for a coagulation screening? Review healing after?
- Extirpation – Get nerve out – inc time before extraction as pain relieved
Positioning of yourself and patient. Can you comfortably place rubber dam?
Referral onto Public Dental Service for bariatric chair for extraction – safer environment
domiciliary care
Rarely the first line option.
Useful option when patients are 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. Full risk assessment (as per any domiciliary visit) is essential.
- Obese individuals are twice as likely to be cared for in nursing homes
domiciliary care options
Treatment is usually restricted to inexpensive, short procedures which carry little risk such as examinations.
The most common type of dental procedure carried out is prosthetics.
Or exam, dressings etc not extirpation
categories of pt requiring domiciliary care (10)
Neurological and mental illness e.g. dementia, dental phobia
Intellectual impairment such as learning disability
Physical impairment due to conditions such as cerebral palsy and epilepsy
Homeless people in hostels
Severe cardiovascular disease e.g. stroke
Severe respiratory disease e.g. COPD Chronic Obstructive Pulmonary Disease
Hospital in patients
Older people
Bariatric patients
Palliative care patients
emergency appointments for
emergency relief of pain treatment only, weighing up risks and benefits.
emergency appointments considerations
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
bariatric care and learning disability
Between 2017 and 2018, obesity was found to be twice as common in patients with a learning disability aged 18–35 than those without.
Those with learning disabilities can experience weight gain, especially those living independently unless they have careful diet control
Thought to be multifactorial, with people with learning disabilities often having poorly balanced diets, more sedentary lifestyles and possible genetic predisposition to weight gain, such is the case in Prader-Willi syndrome or in Down syndrome.
Anti-psychotic medications, such as clozapine and olanzapine, predispose patients to weight gain
anxiety in bariatric pts
study found obese women reported significantly more dental anxiety compared with “normal” weight women when using the Dental Fear Survey (DFS) questionnaire.
inhalation sedation in bariatric pts
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.
intravenous sedation and bariatric pts
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.
general anaesthetic and bariatric pts
Obese patients are twice as likely to develop serious airway problems during a GA than the non-obese
communication and bariatric pts
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
examples of communication to use with bariatric pts that may be favoured
Larger patients may prefer to be referred to as ‘overweight’ rather than ‘obese’
“You are slightly above the weight limit of this chair, we have an alternative chair which we can use”
bariatric surgery - positives
Results in greater improvement in weight loss outcomes, improved control of comorbidities and significant improvement in self-esteem
bariatric surgery - negatives
e.g. nutritional deficiencies, “dumping” syndrome and eating disorders, such as anorexia, bulimia and compulsive eating.
Rapid gastric emptying – diahorrea, nausea, light headed/tired
bariatric surgery correlations with oral problems e.g. (6)
periodontal disease,
increase in dental caries,
hyposalivation,
ulcers,
dentine sensitivity
halitosis.
post bariatric surgery advice
Following surgery, patients are advised to divide food intake into 4-6 meals throughout the day, chewing slowly.
- Higher frequency and prolonged mealtimes
= 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
GDPs diet advice to patients (bariatric especially)
Ingestion of a healthy, balanced diet (reduction in the quantity and frequency of foods and beverages with added sugar, avoid eating at night);
Adequate oral hygiene.
Stimulate salivary flow to avoid dry mouth (increase water ingestion by taking a bottle with you and drinking small sips) +/- artificial saliva;
Increase the consumption of foods rich in fibre;
Chew gum without sugar, but only two month after surgery;
To avoid halitosis or coated tongue, brush the tongue or use a tongue scraper;
Take care to avoid tooth wear (diminish consumption of acidic foods, such as citrus fruit, vinegar and soft drinks);
Drink soft drinks or fruit juices through a straw to minimize contact with the teeth; in case of ingesting soft drinks, never brush right afterwards, but perform mouth rinsing with water;
Never brush the teeth after episodes of vomiting or reflux, if you are not at home, perform mouth rinsing with water or chew gum without sugar; if you are at home: perform mouth rinsing with sodium bicarbonate (one teaspoon in half a glass of water, to alkalinize the oral medium, and wait for half an hour before brushing your teeth).
Provide topical fluoride varnish and OHI as required
malpractice bariatric dental care
“Oral jaw wiring (OJW) or maxilla-mandibular fixation (MMF) have been applied in an effort to control obesity
retainer-like device that makes obese patients take smaller bites, which is custom-made to fit the roof of the patient’s mouth
- Lack of space inside the mouth forces the patient to consume less quantities of food.
several dental journals warning dentists with different articles that use intraoral devices for the treatment of obesity may be considered outside the practice of dentistry and can be considered as malpractice.”