Bariatric Care

Question 1

Overweight/obesity is defined as what?

Answer 1

abnormal or excessive fat accumulation that may impair health

Question 2

What defines someone as a bariatric person?

Answer 2

an individual of any age who has limitation in health and social care due to physical size, health, mobility and environmental access

Question 3

In what BMI range was mental wellbeing shown to be the lowest?

Answer 3

Those within the morbidly obese range

Question 4

What does BMI equal?

Answer 4

BMI=weight in kg/square of height in m

Question 5

What are the pros and limitations of BMI?

Answer 5

Pros=inexpensive, easy to use, same for both sexes and/or all ages of adults Limitations -Doesn’t assess body fat distribution, because it is a measure of excess weight rather than excess body fat -Doesn’t account for factors such as age, sex, ethnicity and muscle mass

Question 6

What are the BMI values for overweight and obese?

Answer 6

overweight = >25kg/m2 Obese = >30kg/m2

Question 8

What is the fundamental cause of obesity?

However, obesity is what kind of disease?

Answer 8

Findamental cause = and energy imbalance between calories consumes and calories expended

However, obesity is a complex, multifactorial chronic disease that is strongly associated with multiple comorbidities.

Question 9

What are some examples of contributing factors to obesity?

Answer 9

• Underlying health problems (hyperthyroidism, eating issues such as Prader-Willi syndrome)
• Lack of energy (so don’t want to exercise)
• Difficulty chewing or swallowing food or its taste or texture (in autism a lot of people will only eat certain foods)
• Medications that increased weight gain/adapt apetitie
• Physical limitations (rheumatoid arthritis, cerebral palsy)
• Lifestyle factors
  
  • Lack of healthy food choices
  • Accessible environments that enable exercise
  • Resources and appropriate support systems (can they afford the gym?)

Question 10

How does the Equality Act 2010 relate to bariatric patients?

Answer 10

It does not classify obesity as a disability but conditions associated with obesity may lead to disability e.g., need a wheelchair for mobility.

Therefore, failure to provide suitable safe facilities for bariatric patients has the potential to breach the Equality Act (2010).

Question 11

What must the dental team do in order to comply with the Equality Act 2010 to make sure disabled have equal access to healthcare?

Answer 11

To make reasonable adjustments to aid universal access to our services

Question 12

What is the rold of the dental team with regards to bariatric patients?

Answer 12

• 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 to Secondary or 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 13

Prior to an appointment with a bariatric patient, what might you want to check beforehand (over the phone)?

Answer 13

Ensure the venue has appropriate facilities for patient care so may have to check the P’s weight/BMI and mobility (do they use a wheelchair?)

Question 14

What might be important to consider regarding travel of the baiatric patient to a dental surgery?

Answer 14

• Are they using private transport? (car, taxi)
  
  • Parking should be available as close to the venue as possible

Question 15

Can ambulances transport bariatric patients to appointments?

Answer 15

No - this is onyl for travel to hospitals

Question 16

What accessibility features should be considered for a bariatric patients?

Answer 16

• Waiting room with suitable weight bearing armless chair
• Adequate door widths
• Accessible toilet facilities
• Is practise accessible via lift or stairs?
• Emergency evacuation possible

Question 17

Should staff ever try to break the fall of an obese patient?

Answer 17

No - under no circumstances

Question 18

With regards to time, what might have to be considered for a bariatric patient?

Answer 18

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

Question 19

What safety aspects should be considered for a bariatric patient?

Answer 19

• Specialist equipment may mean patients need referral to specialist clinics or hospitals
• Wider cuff BP 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 compression may be difficult

Question 20

What is the weight limit for a normal dental chair? What do you do if the patient doesnt know their weight and it may exceed the limit?

Answer 20

22 stone

An accurate weight must be obtained through weighing the patient (however, most standard weighing scales only weight up to 22st)

Question 21

What might an obese patient be at risk of if lying flat in the dental chair for too long?

Answer 21

Risk of hypoxaemia (people who carry weight on their chest and upper body are at risk of this when lying flat)

Note: In extreme circumstances some obese patients may present with obesity hypoventilation syndrome, a result of chronic hypoventilation due to excess wight preventing full expansion of the lungs

Question 23

What are some medical complications of obesity?

Answer 23

• coronary heart disease
• cancer
• Osteoarthritis
• Dyspnoea
• Hypertension
• diabetes
• sleep apnoea
• depression/anxiety
• GORD
• Liver and gallbladder disease
• Skin conditions such as cellulitis and intertrigo

Question 24

Why might treatment be more difficult in bariatric patients?

Answer 24

Loss of anatomial landmarks is possible and there may be access problems with large cheeks, tongue etc.

Question 25

What kind of anaesthesia technique might be difficult in obese patients? What alternative techniques might need to be considered?

Answer 25

• ID blocks
• Gow-Gates or intraligamentary techniques

Question 26

If a dental mirror is insufficient for soft tissue retraction what might you want to use?

Answer 26

a ‘Lax’ tongue retractor

Question 27

In what position might you want to treat bariatric patients?

Answer 27

Semi-supine or sitting upright

Question 28

What problems might there be regarding radiology with a bariatric patient?

Answer 28

Intra-oral radiology can be more challenging due to increased soft tissues

OPT’s can be difficult or even impossible if machine is unable to accommodate the patient’s size

Question 29

Long procedures may lead to what problems in obese patients?

Answer 29

acute leg oedema, cellulitits, Compartment Syndrome and pressure sores

Question 30

Non-alcoholi fatty liver disease is a disease that is associated with obese people. Why is this disease significant to dentists?

Answer 30

coagulation abnormalities may occur with this disease

Question 31

Excessive fat in the tissues can affect drug intake how?

Answer 31

Can affect the pharmalogical absorption of a drug

Question 32

Describe the link between periodotnal disease and obesity.

Answer 32

• There has been a link associating periodontal disease and obesity but no evidence of a causal relationship
• Obesity doesn’t appear to play a negative role in the treatment outcome of non-surgical periodontal surgery

Note: Be aware of the complexity of obesity and be ale to discuss the importance of maintaing a healthy body weight and performing good oral hygiene procedures.

Question 33

Describe the link bewtween obesity and caries.

Answer 33

Bariatric patients may have higher caries rate than general population as causations are interrelatable (diet high in sugars)

Question 34

Describe the link between wound healing and obesity.

Answer 34

Patients more likely to have a reduced immune function leading to delayed wound healing. Significant for procedures such as extractions, surgical periodontal treatment, biopsies.

Question 35

Describe the link between tooth wear and obesity

Answer 35

Erosive tooth wear more likely as there is an increased prevalence of GORD in bariatric people. There is an increased incidence of oesophageal reflux, especially those with gastric banding, causing acid erosion.

Question 36

Domiciliary care is rarely the first line option but can be useful for what patients?

Answer 36

when the patient is too large and/or anxious to leave their home

Question 37

A domiciliary visit may be useful for what kind of appointment?

Answer 37

initial assessment - then arranging further review in clinic

Question 38

What needs to be carried out for every domiciliary visit?

Answer 38

A full risk assessment (is essential)

Question 39

What kind of treatment can be carried out at domiciliary visits? What is the most common kind of dental procedure carried out?

Answer 39

-Treatments are usually restricted to inexpensive, short procedures which caryy little risk such as examinations

Most common = prosthetics

Question 40

Describe how you would deal with an emergency appointment with a bariatric patient.

Answer 40

In these scenarios, provide emergency relief of pain treatment only, weighing up the risks and benefits. The health and safety of the patient and staff should not be compromised at any time. If the patient is unsuitable for your dental chair then consider treating the patient in their wheelchair/a bariatric wheelchair. Any future appontments should be arranged in clinic with suitable facilities.

Question 41

Why is it thought that people with learning disabilities are at risk of becoming obese?

Answer 41

It is 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

Also, anti-psychotic mediacations, such as clozapine and olanzapine, predispose patients to weight gain

Question 42

What kinds of sedation can be used for dental treatment?

Answer 42

• Inhalation sedation
• Intravenous sedation
• General anaesthesia

Question 43

Describe inhalation sedation for bariatric patients, including any indications/contraindications.

Answer 43

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

Question 44

Describe itravenous sedation for bariatric patients, including any indications/contraindications.

Answer 44

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

Question 45

Describe GA for dental treatment in bariatric patients, including any indication or contraindications.

Answer 45

• Obese patients are twice as likely to develop serious airway problems during a GA than non-obese (so probs contraindicated)

Question 46

Exaplain how to communicate effectively with a bariatric patient.

Answer 46

• 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:

• 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”

Question 47

What are the positive outcomes of bariatric surgery?

Answer 47

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

Question 48

What are some negative consequences of bariatric surgery?

Answer 48

nutritional deficiencies_, “dumping” syndrome and eating disorders, such as anorexia, bulimia and compulsive eating.

Question 49

What are the dental implication of bariatric surgery?

Answer 49

Correlation with 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. The 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 50

What simple, clear messages should GDS’s provid to bariactric patients?

Answer 50

• 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

Question 51

Look at oral jaw wiring slide (now seen as malpractise and out of our scope of work)