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BDS 2 > BDS5004: PTSR > Flashcards

BDS5004: PTSR Flashcards

1
Q

Importance of trust

A

Build relationship w/ pt
Greater satisfaction, compliance
Avoid: complaints + legal action

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2
Q

What are the 3 ethical duties of care?

A
  1. Protect pt’s life + health to acceptable professional standard
  2. Respect autonomy
  3. Act justly + fairly
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3
Q

Explain ethical duty 1

A

Do good: act in pt’s interest, promote OH, restore function, relieve pain/infection

Do no harm: cross infection, protect airways, health + safety, maintain competence

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4
Q

Explain ethical duty 2

A

Respect autonomy

Pt has right to info + choice about what happens to own person
Consent, confidentiality, truthfulness

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5
Q

Explain ethical duty 3

A

Act justly + fairly

Don’t discriminate: age, race, gender, sexuality, disability, blood borne infection
Fair distribution of resources

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6
Q

Case vs statute law

A

Case: cases that have come before; set precedent
Statute: laws passed by government

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7
Q

Criminal vs civil cases

A

Criminal: gov does prosecuting; implication for public; murder, fraud
Civil: unlawful touching, negligence; looking for compensation

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8
Q

What 3 criteria must be proved for a legal charge of negligence?

A
  1. Dentist had duty of care to pt concerned
  2. Harm had resulted
  3. Dentist caused the harm
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9
Q

Explain the Bolam test

A

In dispute what would reasonable body of medical opinion do in similar circumstances
Professional standard

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10
Q

Explain the Montgomery standard/Test of Materiality

A

Ensure pts aware of any material risks in proposed treatment and of reasonable alternatives

What would reasonable pt want to be told?

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11
Q

What are the 3 main functions of the GDC?

A
  1. Registration
  2. Education, dental schools, CPD
  3. Discipline health and professional misconduct
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12
Q

What are the 9 GDC standards?

A
  1. Put pts interests first
  2. Communicate effectively
  3. Obtain valid consent
  4. Maintain + protect pt info
  5. Clear + effective complaints procedure
  6. Work w/ colleagues for pts’ best interests
  7. Maintain, develop, work within professional knowledge + skills
  8. Raise concerns if pt @ risk
  9. Maintain confidence in profession + you
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13
Q

Doctrine of Necessity

A

Treat when unconscious/in medical emergency

Would normally be illegal but in certain case is legal

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14
Q

What is informed consent?

A

Permission given in full knowledge of procedure, consequences, risks and alternatives

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15
Q

How must informed consent be gained?

A
  1. Pt must be competent; everyone is unless proven otherwise
  2. Given appropriate info.
  3. Info. understood
  4. Given freely
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16
Q

What 6 pieces of evidence must be given for informed consent?

A
  1. Nature of problem
  2. Treatment procedure
  3. Alternatives - incl. no treatment
  4. Risks + side effects
  5. Benefits
  6. Cost + time
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17
Q

Outline differences between traditional consent and interactive consent

A

Traditional

  • problem defined + explained
  • dentist decides treatment
  • pt told
  • consent assumed unless objected
  • treatment

Interactive

  • problem defined + explained
  • treatment options discussed
  • risks + benefits discussed
  • Qs addressed
  • understanding checked
  • choice agreed
  • explicit consent given
  • treatment
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18
Q

Define health and illness

A

Health: state of complete mental, physical, social wellbeing

Illness: how person feels when unwell and effect on normal everyday life

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19
Q

Define illness behaviour

A

How individual responds to bodily indications and conditions viewed as abnormal
Manner in which they monitor body, define and interpret symptoms, take remedial action and utilise sources of help

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20
Q

What are Mechanic’s 10 variables that affect consulting behaviour?

A
  1. Visibility, recognisability or perpetual salience of signs and symptoms
  2. Extent to which symptoms perceived as serious
  3. Extent to which symptoms disrupt family, work, social activities
  4. Freq./persistence of signs and symptoms
  5. Tolerance threshold of those exposed
  6. Available info., knowledge, cultural assumption of evaluator
  7. Basic needs that lead to denial
  8. Needs competing w/ illness responses
  9. Competing interpretations once recognised
  10. Availability of resources, physical proximity, psychological and monetary cost of action
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21
Q

What are Zola’s 5 triggers for someone to take action?

A
  1. Occurrence of interpersonal crisis
  2. Perceived interference w/ social or personal relations
  3. Sanctioning; peer pressure
  4. Perceived interference w/ vocational or physical activity
  5. Temporalising of symptomatology; if not better by next Tuesday will visit
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22
Q

What are the 5 main barriers to dental attendance?

A
  1. Accommodation: opening hours, distance
  2. Availability: not enough dentists, NHS/private
  3. Accessibility: wheelchair, disabled, ill health
  4. Affordability: treatment and transport
  5. Acceptability: accepting NHS pts, pt happy to attend
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23
Q

Where in dentistry is deliberate dishonesty seen?

A 
Falsification of records
False claims for work not done
Misleading pts
Poor standards of care, cutting corners
Criminal offence
GDC professional misconduct
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24
Q

Why in dentistry is truth telling important?

A 
Experience of being lied to
Professional dishonesty
Ever right to lie?
Always tell truth?
Long term and short term problems
An ethos of telling truth
Be prepared to tell truth
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25
Q

Justifications for and against economising the truth

A

For

  • paternalism in pts best interests
  • truth may be distressing
  • moral tension b/w doing good and not doing harm

Against

  • rights trump preferences
  • respect autonomy (2nd duty of care)
  • truth telling is precondition for informed consent
  • maintains trust
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26
Q

What are the utilitarian moral arguments for and against telling truth?

A

For

  • finding out you’ve been lied to
  • broken trust
  • inconsistent arguments

Against

  • greatest happiness greatest no,
  • ignorance is bliss
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27
Q

What are the deontological arguments for telling truth?

A

Rights based in arguments; right to be told truth
Scruples criterion; don’t make assumptions about others
Need to know truth in order to plan for future
Relationship b/w trust and truth

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28
Q

When might dentists be economical w/ the truth?

A 
Not being honest about pain
Selective treatment options
Not talking about risks
Not mentioning cost
Soaring pt embarrassment 
Avoiding distress
Covering up mistakes
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29
Q

Strategy for breaking bad news

A
  1. Be reasonably certain of facts
  2. Be honest, if you don’t know say so
  3. Find an appropriate time
  4. Privacy
  5. Keep info simple, repeat if necessary
  6. Don’t rush, give people time to digest
  7. Perhaps friend/relative present
  8. Offer follow up
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30
Q

Discuss confidentiality and trust

A

Confidentiality is expected in professional relations
Confidentiality, truth telling, informed consent and respect for autonomy underlie trust
Maintain individual and public trust in dental profession

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31
Q

What are the exceptions to confidentiality?

A

Person gives consent for sharing info
Safe guarding: another at significant risk of harm
Court order

Compulsory

  • notifiable diseases: TB, cholera
  • prevention of terrorism
  • road traffic act

Discretionary

  • DVLA and epilepsy
  • police
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32
Q

Discuss conflicts b/w rights of individual and public interest

A

Personal privacy
Health records: data protection act
- pt access to records
Broken if harm to others/in public interest

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33
Q

Discuss requirements for records

A

Must make and keep contemporaneous, complete and accurate pt records
Expected to be up to date, complete, clear, accurate, legible (if hand written)

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34
Q

Discuss treatment of HIV/AIDs pts

A

No different
Importance of trust and good cross infection control in good dental practice
Duty to treat (3rd duty of care) no different from any other pt

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35
Q

Discuss health related behaviour in dentistry

A

Sugar consumption and caries; advice less sugar (no more 4/day)
OH and gum disease; DM also contributes - treatment may fail if pt decides to change dose/medication
Smoking
Attendance

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36
Q

What is critical autonomy?

A 
Capacity to change behaviour 
3 requirements
- educations; understand why
- mental state; not stressed
- social opportunity; have resources
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37
Q

Reasons for poor compliance

A

Stress, fear, anger, stigmatisation, confidence
Lifestyle; time and effort
Don’t understand need or importance
Social background, cultural expectation, peer pressure
Financial, education
Power imbalance in relationship

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38
Q

Psychological and social reasons for poor compliance

A 
Emotional self confidence 
Social background 
Cultural expectations 
Peer pressure
Attitude of HCP
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39
Q

Discuss treatment of non-compliant pt

A

For

  • req. the treatment
  • may motivate to change/improve

Against

  • not shown sign of improvement
  • treatment will fail, cause more harm
  • req. more treatment/care
  • may complain/sue
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40
Q

Moral importance of health promotion

A

Non-judgemental explanations
Raising expectations, inc. confidence and compliance
Respect for refusals, Long and short term compliance
Personal health education
Public health promotion
Importance of prevention

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41
Q

Discuss relation b/w autonomy and competence

A

Autonomy is assumed unless reason to believe otherwise
Person lacking competence to consent has limited autonomy
Ethical and legal problems in deciding for others who aren’t competent

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42
Q

4 criteria for competence

A
  1. Understanding
  2. Recall
  3. Belief
  4. Rationality
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43
Q

Discuss assessing competence in clinic and problems w/ this

A

Particular situation
May be able to consent to particular procedures but not others; task specific

Competence tests and limitations
History and conversation, clinical judgement
- errors in judgement either way

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44
Q

Discuss adults that may have impaired competence

A

Permanent learning difficulty
Dementia
Temporary psychotic illness

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45
Q

What people play a role in supported decision making for vulnerable adults?

A

Pt
Family/carers
Clinicians
Courts

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46
Q

Discuss role of pt and family/carers in decision making for vulnerable adults

A

Pt: good practice to involve

Family/carer

  • know them well
  • direct interest in health
  • may undertake tooth brushing, food choices, appointment making
  • good practice to consult
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47
Q

Discuss role of clinicians and courts in decision making for vulnerable adults

A

Clinicians

  • understands clinical issues
  • may specialise in special needs dentistry
  • has experience and skill
  • legally can act in pt’s best interest

Courts

  • when decision is difficult or contested
  • when serious consequences
  • refer to family courts for independent legal judgement
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48
Q

Discuss disability and vulnerability in relation to competence

A

16+ who lack capacity, Mental Capacity Act 2005 provides legal framework in England and Wales
Moral issues in deciding for others
Scotland: adults with incapacity act 2000

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49
Q

Discuss the mental capacity act

A

Mental disorder or learning difficulties not grounds for non-capacity
Capacity not assumed by judging pt behaviour or appearance
Take all steps practicable to help pt make decision about treatment before concluding lack capacity
Irrational/unwise not sufficient reason for non-capacity

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50
Q

To have capacity what criteria must a pt meet

A

Understand: info relevant to decision incl. reasonably foreseeable consequences of deciding one way or another, failing to make decision

Retain info

Use/weigh up info as part of decision process

Communicate their decision; verbal, sign language, other

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51
Q

Discuss consent in relation to mental distress

A 
Temporary loss of competence
Compulsory detention under mental health act 
Defer elective treatment
Other treatment still req. consent
Emergency: pt best interest
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52
Q

Discuss informed consent in children

A

16: age of maturity for medical consent
<16 consent given by parent
18: age of refusal; case law

Family law reform act 1969
Child assent: ortho

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53
Q

Discuss who is a parent for child consent

A

Biological mother

Father; if married to mother at birth or named on birth certificate

Person granted legal parental responsibility

For simple procedures, person who has charge of child

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54
Q

Discuss mature children and the req. for Gillick competence

A

Law allows children <16 who don’t want to involve parents to be treated as adults for confidentiality and consent;

  • if they understand
  • are judged mature enough
  • treatment is in best interests
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55
Q

What is good practice for treating children?

A

Difference b/w legal and moral
Importance of good management; involve, stickers, friendly environment
Tell, ask, show, do; seek permission
Dental care for lifetime; happy to return

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56
Q

Who is deemed vulnerable? What is the tension with treating vulnerable pt?

A

Anyone who has to rely on someone else to care for them

Mora tension b/w not forcing treatment and neglect for health
- resolved by good management

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57
Q

How are dental health needs of population met?

A

Epidemiological surveys; National Adult Dental Health survey

  • evidence for planning services to meet needs
  • moral importance of reliable info. rather than guessing
  • 2009: improvements, still inequalities

Meeting needs of whole community

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58
Q

Discuss the proposed new dental contract

A

System based on registration, capitation and quality
Preventive
- practice delivered by whole team
- allow expanded role: hygienists, therapists, oral health educators, expanded duty nurses
Care pathways based of detailed oral health assessment
Care plans to engage pt in healthcare and team in EB oral care and prevention
Risk screening using algorithms deliver individual risk assessments based on care, full history, exam

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59
Q

Discuss the oral health assessment in the new dental contract

A

Assess

  • caries
  • periodontal health
  • tooth surface loss
  • soft tissue health
Pt scored red, amber, green on each domain
Advanced care not provided if red.
- endodontics
- mental based denture
- indirect restoration 
- advanced periodontal care
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60
Q

Discuss the ethical issues with the new dental contract

A

Risk status defined by computer algorithms
Red status for caries/PD health; not entitled to advanced care on NHS (controversial)
NHS/private: pt entitlement on NHS clear, offering privately may generate problems if not part of plan
Consent: pt may wish to have treatment not following care pathway

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61
Q

Discuss ethics of allocation of health resources

A

Everyone has right to health care
Utilitarian and deontological theories, justice and fairness

Macro dental budget within health care
Micro allocation, pt charges, surgery siting

3rd duty of care

  • current conflicts in organisation create discrimination
  • more dentists pp London, south England (wealthier)
  • poorer areas have less access
  • wealthier people can afford to pay for care
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62
Q

4 methods of funding dentistry and arguments for and against

A
  1. NHS contract w/ independent practitioner
    - paid on per treatment basis
    - work efficiently, quickly
    - may over treat, too fast, low quality
  2. NHS salaried: CDS, forces, hospital, teaching
    - not work as efficiently
    - take more time
    - work less
  3. Solely private practice: independent pt, insurance
    - more choice, take time
    - paying for prevention, charge higher prices
  4. Mixed practice
    - fragmentation of services
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63
Q

Challenges in funding of dental services

A 
Over and under treatment 
Fragmentation of services 
Paying for prevention 
Loss of concept of dental fitness
Potential for professional abuse of systems 
Qs about access

Importance of moral integrity

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64
Q

Discuss modernising of NHS dental (2000)

A

Universal service based on clinical needs
Comprehensive range of services
Responsiveness to needs of different populations
Continuous improvement of services
Support for staff
Public funds devoted to NHS pts
Cooperation w/ others
Work to red. inequalities
Open access to info. about services and treatment

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65
Q

Moral importance prevention v cure

A

Health benefits
Best use of scarce resources
Public health approaches
- fluoridation, sugar tax
- benefit children, vulnerable adults; those least likely to receive dental care
- dentist has more time to treat those most in need
Back to health promotion

66
Q

Relationship of good business and ethics

A

Go hand in hand

Practice w/ good management and good practice
- dentists happier, more fulfilled, less stressed
Efficient and effective use of resources

67
Q

Define inequalities in health?

A

Unjust or unfair differences in health determinants or outcomes within or b/w defined popn.

68
Q

Define social class

A

Segments of popn. sharing brooding similar types of resources, levels and styles of living and (for some) shared perception of their collective condition

69
Q

Discuss Marx’s concept of class

A

2 classes in perpetual conflict

  • Bourgeoisie; capitalist class
  • Proletariat; working class

Classes in conflict but dependent on each other

Different interests

  • higher profit
  • higher wages

Bourgeoisie manipulate proletariat via ideology and exploit their labour by making more profit than is given in wages

Due to motives class conflict inevitable, locally and globally

70
Q

Discuss National Statistic Socio-Economic Class Classification

A
  1. Senior professionals/Senior managers
  2. Associate professionals/Junior managers
  3. Other administrative and Clerical workers
  4. Own-account non-professionals
  5. Supervisors, technicians, related workers
  6. Intermediate workers
  7. Other workers
  8. Never worked/other inactive
71
Q

Different models of explanation for inequalities in health

A

Materialist
Behavioural
Psychosocial
Life-course

72
Q

Materialist model of social inequality

A

Differences in environmental and living conditions b/w classes responsible for health status differences

73
Q

Behavioural model for health inequalities

A

Differences in health related behaviour b/w classes responsible for health status inequalities

74
Q

Psychosocial model for health inequalities

A

Lower socioeconomic status directly affects psychosocial well-being, has direct biological effect on health

Stress and PD disease
Sense of coherence and poor OH
B/w work and/or marital stress and poor OH

75
Q

Life-course model for health inequalities

A

Disadvantages either seen to accumulate overtime or be result of critical episodes which affect future development

76
Q

Steps to reduce inequality in healthcare

A

Work in partnership w/

  • other members dental team
  • HCP; environment supports health, targets underlying health determinants
  • agencies; schools, food industry, authorities

Close gap b/w rich and poor; tax credits

Close working w/ parents

  • red. sugary drink intake
  • inc. fruit and vegetable intake
  • regular tooth brushing

Fluoridation
Creating healthier school/work environments
Removal VAT from OH products
Chair-side prevention; FS

77
Q

Define ethnicity

A

Segment of larger society seen by others to be different in some combination of; language, religion, race, ancestral homeland w/ related culture
Members also perceive themselves in this way and participate in shared activities built around their common origin or culture

78
Q

Compare race and ethnicity

A

Race

  • classification of human beings according to physical characteristics (genetic homogeneity)
  • biological differences restricted to skin colour, bone structure, hair colour
Ethnicity
- social concept applied to social groups
- share common characteristics associated w/ race and unique culture
— cultural heritage
— common language
— religion and values
— customs 
— common history
79
Q

Main ethnic groups in UK

A

White British
Irish
Gypsy

Indian
Pakistani
Bangladeshi
Chinese

African
Caribbean

80
Q

Equality Act 2010

A

Race cannot be used as a reason to treat someone unfairly

Includes in/direct discrimination, harassment, victimisation

81
Q

Main factor causing ethnic health inequality

A

Poorer socioeconomic background

82
Q

Discuss inequalities in caries and edentulousness

A

Caries

  • pre-school children ethnic groups higher rates
  • children white Eastern European, Pakistani, Bangladeshi > white

Edentulous
- white British, Caribbean > African, Bangladeshi, Indian, Chinese, Pakistani

83
Q

Discuss inequalities in oral cancer

A

Higher rates in some ethnic groups due to tobacco, alcohol
Also may use cancer services less

Asian adults highest rates
Chinese adults more likely develop nasopharyngeal cancer
Asian and Chinese adults younger when diagnosed

84
Q

Discuss inequalities in knowledge and dental attendance

A

Knowledge
- inc. w/ British born ethnic parent but caries rates higher than in immigrant

Attendance

  • <15% Asian >55 attend regularly
  • south Asian children Birmingham disproportionately more likely to use CDS than be registered to GDP
85
Q

6 possible explanations for ethnic inequalities in health

A
  1. Statistical artefact
  2. Consequence of migration process
  3. Genetic/biological differences
  4. Differences in cultural and consequent health behaviour
  5. Consequences of socioeconomic disadvantage
  6. Experience of racism and racial harassment
86
Q

What can dental professionals do to overcome ethnic health inequalities

A

Implementation of cross-cultural pt-instructor programme to improve students’ understand of and attitudes towards ethnically diverse pts

Provide info in different languages

Employ multilingual staff

Understand cultural variations

87
Q

Define gender

A

Social construction of meanings, rules, values overlaid on biological differences of M and F
- how we behave, feel, think, dress and social roles we fill as M and F

88
Q

Explain differences in mortality b/w M and F and 8 reasons why

A

M>F

Reasons

  • drink more
  • drive more and faster
  • work in dangerous areas
  • take part in dangerous leisure activities
  • more accidents
  • more vulnerable to suicide
  • subject to murder
  • take less good care of health
89
Q

Discuss gender differences in morbidity

A

F

  • consistently more likely to rate health as not good
  • 2-3% more likely to suffer long-standing illness
  • 4% more likely to suffer limiting long-standing illness
  • 1-3% more report more problems w/ pain, mobility, self-care, performing normal activities
  • 7% more report anxiety and depression
90
Q

Discuss gender differences in illness behaviour

A

F

  • more likely to consult HCP, consult more for each condition, take more prescribed drugs
  • average 5 consultations/yr; M only 3
  • consult for mental health (esp. anxiety, depression); 2x likely to have treatment
  • consult more for preventive care, self-examine more, take more health supplements
91
Q

Discuss gender differences in oral health

A 
F
- more likely have 
— 1/+ filling
— crowns
— v healthy PD condition 
— endentulism
- suffer less oral cancer
- higher levels dental anxiety
- attend more regularly

M
- more likely have
— coronal and root caries
— greater proportion of restorations w/ 2ry caries and unsound restorations
- higher prevalence tooth wear, more severe tooth wear

92
Q

Discuss eating and mental disorders F are more likely to suffer from and their dental impact

A

Eating

  • anorexia, bulimia
  • dental erosion

Mental

  • stress, depression
  • atypical facial pain
  • temporomandibular disorders (3x as likely)
93
Q

Discuss reasons for gender differences in health behaviour

A

F attend more as
- more anxious about health; report more worry, pain, symptoms relating to oral health
- take children
- as attend more, have more knowledge and more likely to follow advice
F more concerned about facial appearance
M at all ages less concerned about dental health

94
Q

Define health behaviour and health attitudes

A

Behaviour: actions taken by healthy person to enhance/maintain health

Attitude: individuals’ view of obesity, drugs, mental, physical illness etc

95
Q

How do we influence behaviour but why is the behaviour not sustained?

A

Knowledge influences behaviour; if lack can’t make change/fix

Knowledge alone doesn’t confer behaviour as behaviour needs to be learned and reinforced; other factors influence behaviour

96
Q

Discuss 2 types of conditioning involved in learning theory

A

Classical

  • involuntary behaviours
  • stimuli associated w/ action will trigger response by itself when becomes conditioned
  • calling dog to food will trigger salivating

Operant

  • voluntary behaviours
  • learned through reinforcement and punishment
97
Q

Discuss the A B C of learning theory

A

Antecedents

  • environmental stimuli associated w/ behaviour
  • presence inc. likelihood of behaviour

Behaviour

Consequences
- make behaviour more/less likely to occur in future

98
Q

Explain the types of punishment and reinforcement

A

Punishment
+: -ve outcome applied; belt/whip, verbal reprimand
-: remove something you like; no phone

Reinforcement
+: give something you like; receive donuts
-: remove something don’t like; escape/avoid bad outcome

99
Q

Discuss shaping conditioning in learning behaviour

A

Differential reinforcement method

Method of successive approximation
- get closer and closer to desired action
Complex behaviours learned in small steps
Reward behaviours that are inc. similar to desired behaviour

100
Q

Discuss social learning theory

A

Observational (vicarious) learning
- observe behaviours of others and consequences of those behaviours

Vicarious reinforcement
- if their behaviours are reinforced tend to imitate those behaviours

101
Q

Give examples of social learning theory

A

Child and parent interactions

- children imitate parents’ behaviours good and bad

102
Q

Discuss expectancy-value

A

Potential for behaviour to occur on any specific situation is function of expectancy that behaviour will lead to particular outcome and value of that outcome

103
Q

Discuss self-efficacy and factors affecting it

A

Individuals belief in their ability to succeed in specific situation

Outcome efficacy: individuals’ expectation that behaviour will lead to specific outcome

Efficacy expectancy: belief that one can execute behaviour req. to produce outcome

Factors

  • mastery experience; do I know how
  • social learning; do other people do it
  • verbal persuasion or encouragement
104
Q

Discuss the 5 factor health belief model

A

Attitudes that lead to health behaviours

  1. General health values
  2. Threat to health posed by problems
  3. Belief in personal vulnerability
  4. Belief in response efficacy; will treatment avoid outcome
  5. Belief in self-efficacy
105
Q

Discuss the engineering and physiological models of stress

A

Engineering

  • external stress gives rise to strain in individual
  • based on physics concepts

Physiological

  • stress defined as what happens within person
  • stress defined as particular response irrespective of external stimuli
  • adrenaline and cortisol
106
Q

Discuss the transactional model of stress

A

Stress is condition that results when transaction b/w person and environment leads to individual to perceive discrepancy b/w demands of situation and their coping resources

107
Q

Discuss the appraisal steps involved in transactional model of stress

A

Proposed we go through 2 major appraisal steps in response to stressful situation

1ry: perception of how threatening situation is to individual
2ry: perception of what coping resources are available

108
Q

Discuss relation b/w stress and body function

A

Psychoneuroimmunology

  • stress -> inc. cortisol -> immunosuppression -> bacteria flourish
  • stress -> red. mucosal healing

Functional oral problems; grinding/TMJD

109
Q

How does stress lead to disease?

A

Behavioural and physiological changes

110
Q

Discuss behavioural changes associated w/ stress

A

Omission

  • red. dental care
  • inc. missed appointments
  • changes in routine care
  • inc. forgetfulness

Commission

  • inc. -ve coping behaviours; smoking, alcohol, diet (Steptoe et al, 1996)
  • automatic/impulse behaviour; grinding, clenching
111
Q

Discuss the physiological changes seen in stress

A

Cortisol suppresses immune system

IL-1 dec. by 60% during exam period (Marucha et al, 1996)

112
Q

What dental problems are associated w/ stress?

A 
TMJD
Bruxism
Canker sores
Dry mouth 
Burning mouth syndrome
Lichen planus
Gum disease (Croucher et al, 1997)
Caries (Sutton, 1965)
113
Q

Define ageing and ageism

A

Ageing: process of growing old; biomedical and social models

Ageism: stereotyping of and discrimination against someone due to age

114
Q

Compare the biomedical and social models of ageing

A

Biomedical

  • views human ageing as physiological and biological change
  • seen as determined by inbuilt biological process
  • focuses on mechanical process of ageing
  • different parts of body age @ different rates
  • old age seen as form of disease or co pled of conditions that are treatable

Social model

  • implies importance of social factors in shaping experiences of growing old
  • ageing shapes by socioeconomic conditions and cultural values throughout life
  • each cohort experiences different social, cultural, economic conditions specific to their time
  • older people are not homogenous group
  • health and illness influenced by social roles
115
Q

Discuss common oral health problems in older people

A 
Edentulism; improving 
Xerostomia; due to polypharmacy
PD disease; common due to irreversible nature
Oral cancer
Root caries
116
Q

Discuss the social impact of dental problems for older people

A

Avoid conversation
Eating difficulties
Not smile
Stay inside if have no teeth/can’t tolerate dentures

117
Q

Discuss the treatment issues seen w/ older people

A

Older people viewed as less satisfying to teach
Use stereotypes, over simplification
-ve attitudes towards edentulous pt

118
Q

Possible explanations for age differences in oral health

A

Tooth loss seen as inevitable
Less likely to look for preventive treatment; tooth loss expected
Dentures/treatment costs could be prohibitive
- more likely to be poor
Dentistry focuses on maintenance of youth and young teeth

119
Q

Discuss the implication on NHS of oral health problems in old age

A

More older people retaining teeth w/ complex restorations; req. restorative specialists

Prevention of disease

47% 85+ edentate; req. gerodontologists

Financial burden

Use of dental skill mix

120
Q

Distinguish fear, anxiety, phobia

A

Fear: painful emotion excited by danger or apprehension of danger

Anxiety: state of unease caused by fear and apprehension

Phobia

  • fear out of proportion to demands of situation
  • can’t be reasoned or explained away
  • beyond voluntary control
  • leads to avoidance behaviour
121
Q

4 types of anxiety/fear seen in dentistry

A
  1. Generalised anxiety disorder
  2. Specific dental phobia
    - fear of specific stimuli
    - gagging, fear of catastrophe
    - fear of losing control
    - fear of fainting, adverse reaction
  3. PTSD: previous trauma
  4. Social/interpersonal fears
    - embarrassment of OH
    - distrust of HCP: helplessness, humiliation, suspicion/doubt
122
Q

Consequences of dental anxiety/phobia

A

Avoidance/attendance: cancellation, deferring treatment
Complexity/OH: sedation, inc. complexity, longer time,OH deteriorate
Personal: shame, maintenance of anxiety/avoidance

123
Q

Discuss assessment of dental anxiety

A

Modified dental anxiety scale (MDAS)

Simple
Good internal validity
Used throughout clinical studies
Used as clinical screen
5 questions, 5 options scoring 1-5
19/25 = anxious/phobic
124
Q

How is dental anxiety acquired?

A

Direct exposure; classical condition
Social/vicarious learning
Transmission of info and meaning; operant conditioning

125
Q

Explain how classical conditioning can lead to dental anxiety

A

Direct exposure

Neutral stimulus (dentist) + unconditioned stimulus (pain from LA/XLA) = unconditioned response (fear)
Due to associated dentist becomes conditioned response which results in conditioned response of fear

Generalisation
Other neutral stimuli (appointment card) become conditioned also resulting in conditioned response (fear)

126
Q

Evidence for classical conditioning in dental anxiety and limitations

A

Evidence; Lautch et al, 1971
- 100% dental phobics reported previous dental trauma

Limitations

  • uneven distribution of dears across fear objects (can’t assign fear to orange)
  • intergenerational commonality of fears
  • learning w/o direct experience
  • onset related to stage of cognitive development and meaning of stimulus
127
Q

Explain how vicarious learning and transmission of info and meaning can cause dental fear acquisition

A

Vicarious learning

  • parents/siblings
  • peers/media
  • see their behaviour and consequences

Transmission of info and meaning
- told/read how many people hurt by dentist causing anxiety of dentist

128
Q

Explain how operant conditioning plays role in development and maintenance of dental anxiety/phobia

A

Behaviour that gives rise to +ve consequence, inc. in freq.

Avoidance of conditioned stimuli (dentist) = red. in fear (-ve reinforcement)
Thus avoidance behaviour inc. (red. behaviour freq.) and response (fear) to conditioned stimulus (dentist) never extinguished

129
Q

Pathway to extinguish dental anxiety

A

Behavioural therapy

  • systematic desensitisation/graded exposure
  • imaginary/virtual exposure

Relaxation techniques (physiological intervention)

Social learning: modelling interventions (funny masks)

Info/meaning: educational intervention, cognitive intervention

130
Q

Chair side techniques for extinguishing anxiety

A

Non-relaxation: communication, distraction
Quasi-relaxation: guided imagery
Relaxation: progressive muscle relaxation

131
Q

Discuss management of low level anxiety pt in practice

A

Children

  • rapport
  • voice control
  • distraction
  • modelling
  • memory reconstruction
  • environmental changes

Adult

  • enhancing sense of control
  • cognitive distraction
  • environmental changes
132
Q

Discuss management of moderate and severe anxiety pt in practice

A

Moderate: supply info

  • procedural; ‘going to give injection’
  • sensorial; ‘feel sharp scratch’
  • coping; ‘breathe deeply to reduce pain’

Severe

  • CBT: in absence of other psychological factors
  • pharmacotherapy
133
Q

Define pain

A

Unpleasant sensory and emotional experience associated w/ actual or potential tissue damage or described in terms of such damage

134
Q

Descartes theory of pain

A

Specificity theory

Specific degree of pain travels to centre in head
Specific dose equates to specific severity

135
Q

Biological theory of pain

A

Peripheral pain mechanisms

A fibres: fast, 0.1s, myelinated

  • A-delta: small fibres, sharp localised distinct pain
  • A-beta: large fibres, don’t carry specific pain info

C fibres: slow, 1/+s, unmyelinated

  • diffuse, dull, aching, burning
  • more complete pain info
136
Q

Shortcomings of the biological theory of pain

A

Activation of nociceptive response is not experience of pain itself
Pain w/o stimulus: phantom limb/dental pain
Stimulus w/o pain: relationship b/w wound severity and pain
- soldiers experienced less pain, request less medication than civilians w/ similar wounds
- soldiers have ‘satisfaction’ reward as no longer in war

137
Q

Gate theory of pain

A

Gate mechanism receives PNS physiological info. and CNS psychological info.
- combined info. controls whether and degree of pain is felt

Mechanism

  • gate open: signal passes to transmission cells, impulse to brain; pain recorded
  • gate closed: no transmission to brain

Gate control

  • pain fibres receive stimulus
  • info. from other peripheral nerves
  • info. from brain
138
Q

Dimensions of pain

A

Sensorial: discriminative

  • localisation, intensity, quality
  • what is this, how painful, what kind of pain

Affective: motivational

  • emotional aspects; this is horrible
  • arousal: inc. HR
  • behavioural: avoidance

Cognitive: evaluative

  • attentional processes
  • anticipation
  • memory of past pain experience
139
Q

Relationship b/w pain and anxiety

A

Anxiety exacerbates pain
Expect greater pain, experience normal/low pain but don’t learn; still predict high levels of pain

Low level anxiety pt would learn level of pain to expect

140
Q

Reasons for discrepancies b/w predicted and actual pain

A

Experiences too far apart (forget/perpetuate)
Stronger memory of painful experiences
Processing of experience
Anxiety disrupting learning; don’t learn level of pain, continue to expect high level

141
Q

4 environmental pain determinants

A

Context
Predictability
Controllability
Distraction

142
Q

Discuss context as attenuating factor of pain

A

Dental personnel

  • conditioned stimuli for fear/pain
  • means of calming and red. pain

Dworkin and Chen (1982)

  • electric shock to incisors
  • those in clinical setting lower pain threshold (start of pain) and tolerances (becomes unbearable)
143
Q

Role of predictability/expectancy in pain perception

A 
Anderson and Pennebaker 1980
Students place hand in apparatus of vibrating sandpaper
Told
- pleasant 
- painful
- nothing

Neutral and pleasant groups had pleasant experience
Painful group had painful experience

144
Q

Role of distraction in pain perception

A

Anxiety vs attention
- high and low level anxiety pt experience less pain when distracted

Gardener and Licklinder 1959

  • audio-analgesia; music or white noise
  • 63% complete anaesthesia, further 25% adequate

More immersive/involving greater anaesthesia
- video/game better than audio

145
Q

Effect of perceived control on pain perception

A

Thrash et al 1982

Pt given signalling device to indicate level of discomfort
Groups
- perceived and actual feedback (can control temp./sensation)
- perceived feedback
- no feedback
Group 1 reported less pain used red light less

146
Q

Emotional determinants of pain perception

A

Mowrer’s 2 factor theory: operant conditioning
Davey’s model
Fear-avoidance model
Acceptance-based models

147
Q

Fear avoidance model of pain perception

A

Physical strain/injury followed by pain leads to either

  • experience of little/no fear about context pain occurred -> return to normal functioning
  • catastrophising pain and context -> self-perpetuating cycle of inc. fear and attenuated pain experience
148
Q

Role of avoidance in pain perception

A

Most opt to get experience out of way; delay = inc. dread + pain

Temporal distance

  • intermediate delay = inc. dread
  • extended delay = red. dread, inc. exponentially w/ T, inc. pain

Learned avoidance

  • phobics attend in severe pain = more severe disease + inc. dread amplify pain experience
  • learn to associated dentist w/ pain reinforcing avoidance and inc. dread
149
Q

Define placebo effect and possible mechanisms for it in relation to pain

A

Improvement in condition of sick person in response to treatment but can’t be considered due to treatment used

Mechanisms

  • expectancy; expect less pain
  • conditioning
  • anxiety/attention; red.
  • endogenous opiates
150
Q

How is pain measured?

A

Subjective
- verbal
— unstructured
— verbal rating scale; mild, mod., severe
- visual/graphic scales; visual analogue scale
Behavioural
Psychological

151
Q

Discuss inc. predictability in relating to coping w/ treatment

A

Preparation

Providing sensory and procedural info red. pain, stress, improve outcomes

Procedural: info about procedure
Sensory: info about sensations may experience

Dual Process Hypothesis

  • sensory and procedural work in different ways
  • together provide biggest benefit
  • procedural: allow pt match ongoing events w/ expectations in non-emotional manner
  • sensory: mapping non-threatening interpretation on to expectations
152
Q

Discuss inc. control in relation to coping w/ treatment

A

Giving pt control dec. stress, pain, discomfort; inc. satisfaction, outcomes

Thrash et al 1982

Given remote w/ lights

  • dentist see and stop
  • thought dentist could see but not connected
  • monitor discomfort

Group w/ most control record less pain and used light less

153
Q

Discuss coping strategies for dealing w/ treatment

A

Problem focussed
- change environment or change actions or attitudes

Emotional focussed
- manage stress-related emotional physical responses in order to maintain morale and allow one to function

Problems come as dentists prefer problem focussed and use w/ pt
- children prefer emotional focussed and using problem may inc. anxiety

154
Q

Discuss presence of parent in relation to children coping w/ treatment

A

Frank et al 1995: children’s distress during immunisation correlated w/ distress shown by parents

Marzo et al 2003: 89% children fully cooperative parent absent cf 63% parent present

155
Q

Discuss modelling intervention for helping children cope w/ treatment

A

Weinstein et al 2003

Children shown procedural video of what injection is, feels like, hand signal to stop had significant red. distress compared to children shown Disneyland

Young children: shown just before procedure
Older: 4-7d before

156
Q

Discuss the combined approach for helping children cope w/ treatment

A

Best method

Tell: simple, matter of fact language; told what is going to happen
Show: using inanimate object
Do: procedure begins when child understands what will be done

157
Q

Factors affecting compliance

A

Characteristics of regime

  • complexity/duration
  • cost
  • side effects

Pt-practitioner relationship

  • satisfaction
  • comprehension: simply for them
  • recall

Psychosocial variables

  • health beliefs; perceived necessity
  • self-efficacy
  • social support
158
Q

Relationship b/w satisfaction and attendance

A

Direct

Satisfaction correlated w/ attending preventative checkups and attending dentist in last 6/12

159
Q

6 methods to improving satisfaction and compliance

A 
Continuity of care: same clinician 
Reputation: teaching hospital
Support services: team effort needed
Consultation style
Info for pt: in writing 
Pt involvement
160
Q

Discuss consultation style for improving satisfaction

A

Szaz and Hollander 1956

Guidance-cooperation: tell pt what to do, pt obey (acute infection)
Mutual participation: help pt help them self (chronic)

Activity-Passivity: do something to pt, pt recipient (coma, trauma)

161
Q

Discuss pt involvement for inc. satisfaction

A

Lefer et al 1962

Involve in decision making process; give options, allow them to choose
Pt happier, satisfied
Req. fewer adjustments
Less lie,y reject treatment, complain

162
Q

Factors affecting pt recall of info

A 
Order of presentation 
- primacy and recency: important info first, summarise at end
Emphasis: highlight key points
Amount: brief detail, plain language
Mode: verbal and writing

BDS 2 (4 decks)

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