BDS5004: PTSR Flashcards
1
Q
Importance of trust
A
Build relationship w/ pt
Greater satisfaction, compliance
Avoid: complaints + legal action
2
Q
What are the 3 ethical duties of care?
A
- Protect pt’s life + health to acceptable professional standard
- Respect autonomy
- Act justly + fairly
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
4
Q
Explain ethical duty 2
A
Respect autonomy
Pt has right to info + choice about what happens to own person
Consent, confidentiality, truthfulness
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
6
Q
Case vs statute law
A
Case: cases that have come before; set precedent
Statute: laws passed by government
7
Q
Criminal vs civil cases
A
Criminal: gov does prosecuting; implication for public; murder, fraud
Civil: unlawful touching, negligence; looking for compensation
8
Q
What 3 criteria must be proved for a legal charge of negligence?
A
- Dentist had duty of care to pt concerned
- Harm had resulted
- Dentist caused the harm
9
Q
Explain the Bolam test
A
In dispute what would reasonable body of medical opinion do in similar circumstances
Professional standard
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?
11
Q
What are the 3 main functions of the GDC?
A
- Registration
- Education, dental schools, CPD
- Discipline health and professional misconduct
12
Q
What are the 9 GDC standards?
A
- Put pts interests first
- Communicate effectively
- Obtain valid consent
- Maintain + protect pt info
- Clear + effective complaints procedure
- Work w/ colleagues for pts’ best interests
- Maintain, develop, work within professional knowledge + skills
- Raise concerns if pt @ risk
- Maintain confidence in profession + you
13
Q
Doctrine of Necessity
A
Treat when unconscious/in medical emergency
Would normally be illegal but in certain case is legal
14
Q
What is informed consent?
A
Permission given in full knowledge of procedure, consequences, risks and alternatives
15
Q
How must informed consent be gained?
A
- Pt must be competent; everyone is unless proven otherwise
- Given appropriate info.
- Info. understood
- Given freely
16
Q
What 6 pieces of evidence must be given for informed consent?
A
- Nature of problem
- Treatment procedure
- Alternatives - incl. no treatment
- Risks + side effects
- Benefits
- Cost + time
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
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
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
20
Q
What are Mechanic’s 10 variables that affect consulting behaviour?
A
- Visibility, recognisability or perpetual salience of signs and symptoms
- Extent to which symptoms perceived as serious
- Extent to which symptoms disrupt family, work, social activities
- Freq./persistence of signs and symptoms
- Tolerance threshold of those exposed
- Available info., knowledge, cultural assumption of evaluator
- Basic needs that lead to denial
- Needs competing w/ illness responses
- Competing interpretations once recognised
- Availability of resources, physical proximity, psychological and monetary cost of action
21
Q
What are Zola’s 5 triggers for someone to take action?
A
- Occurrence of interpersonal crisis
- Perceived interference w/ social or personal relations
- Sanctioning; peer pressure
- Perceived interference w/ vocational or physical activity
- Temporalising of symptomatology; if not better by next Tuesday will visit
22
Q
What are the 5 main barriers to dental attendance?
A
- Accommodation: opening hours, distance
- Availability: not enough dentists, NHS/private
- Accessibility: wheelchair, disabled, ill health
- Affordability: treatment and transport
- Acceptability: accepting NHS pts, pt happy to attend
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
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
25
Justifications for and against economising the truth
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
26
What are the utilitarian moral arguments for and against telling truth?
For
- finding out you've been lied to
- broken trust
- inconsistent arguments
Against
- greatest happiness greatest no,
- ignorance is bliss
27
What are the deontological arguments for telling truth?
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
28
When might dentists be economical w/ the truth?
```
Not being honest about pain
Selective treatment options
Not talking about risks
Not mentioning cost
Soaring pt embarrassment
Avoiding distress
Covering up mistakes
```
29
Strategy for breaking bad news
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
30
Discuss confidentiality and trust
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
31
What are the exceptions to confidentiality?
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
32
Discuss conflicts b/w rights of individual and public interest
Personal privacy
Health records: data protection act
- pt access to records
Broken if harm to others/in public interest
33
Discuss requirements for records
Must make and keep contemporaneous, complete and accurate pt records
Expected to be up to date, complete, clear, accurate, legible (if hand written)
34
Discuss treatment of HIV/AIDs pts
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
35
Discuss health related behaviour in dentistry
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
36
What is critical autonomy?
```
Capacity to change behaviour
3 requirements
- educations; understand why
- mental state; not stressed
- social opportunity; have resources
```
37
Reasons for poor compliance
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
38
Psychological and social reasons for poor compliance
```
Emotional self confidence
Social background
Cultural expectations
Peer pressure
Attitude of HCP
```
39
Discuss treatment of non-compliant pt
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
40
Moral importance of health promotion
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
41
Discuss relation b/w autonomy and competence
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
42
4 criteria for competence
1. Understanding
2. Recall
3. Belief
4. Rationality
43
Discuss assessing competence in clinic and problems w/ this
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
44
Discuss adults that may have impaired competence
Permanent learning difficulty
Dementia
Temporary psychotic illness
45
What people play a role in supported decision making for vulnerable adults?
Pt
Family/carers
Clinicians
Courts
46
Discuss role of pt and family/carers in decision making for vulnerable adults
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
47
Discuss role of clinicians and courts in decision making for vulnerable adults
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
48
Discuss disability and vulnerability in relation to competence
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
49
Discuss the mental capacity act
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
50
To have capacity what criteria must a pt meet
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
51
Discuss consent in relation to mental distress
```
Temporary loss of competence
Compulsory detention under mental health act
Defer elective treatment
Other treatment still req. consent
Emergency: pt best interest
```
52
Discuss informed consent in children
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
53
Discuss who is a parent for child consent
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
54
Discuss mature children and the req. for Gillick competence
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
55
What is good practice for treating children?
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
56
Who is deemed vulnerable? What is the tension with treating vulnerable pt?
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
57
How are dental health needs of population met?
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
58
Discuss the proposed new dental contract
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
59
Discuss the oral health assessment in the new dental contract
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
```
60
Discuss the ethical issues with the new dental contract
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
61
Discuss ethics of allocation of health resources
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
62
4 methods of funding dentistry and arguments for and against
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
63
Challenges in funding of dental services
```
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
64
Discuss modernising of NHS dental (2000)
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
65
Moral importance prevention v cure
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
Relationship of good business and ethics
Go hand in hand
Practice w/ good management and good practice
- dentists happier, more fulfilled, less stressed
Efficient and effective use of resources
67
Define inequalities in health?
Unjust or unfair differences in health determinants or outcomes within or b/w defined popn.
68
Define social class
Segments of popn. sharing brooding similar types of resources, levels and styles of living and (for some) shared perception of their collective condition
69
Discuss Marx's concept of class
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
Discuss National Statistic Socio-Economic Class Classification
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
Different models of explanation for inequalities in health
Materialist
Behavioural
Psychosocial
Life-course
72
Materialist model of social inequality
Differences in environmental and living conditions b/w classes responsible for health status differences
73
Behavioural model for health inequalities
Differences in health related behaviour b/w classes responsible for health status inequalities
74
Psychosocial model for health inequalities
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
Life-course model for health inequalities
Disadvantages either seen to accumulate overtime or be result of critical episodes which affect future development
76
Steps to reduce inequality in healthcare
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
Define ethnicity
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
Compare race and ethnicity
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
Main ethnic groups in UK
White British
Irish
Gypsy
Indian
Pakistani
Bangladeshi
Chinese
African
Caribbean
80
Equality Act 2010
Race cannot be used as a reason to treat someone unfairly
| Includes in/direct discrimination, harassment, victimisation
81
Main factor causing ethnic health inequality
Poorer socioeconomic background
82
Discuss inequalities in caries and edentulousness
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
Discuss inequalities in oral cancer
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
Discuss inequalities in knowledge and dental attendance
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
6 possible explanations for ethnic inequalities in health
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
What can dental professionals do to overcome ethnic health inequalities
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
Define gender
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
Explain differences in mortality b/w M and F and 8 reasons why
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
Discuss gender differences in morbidity
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
Discuss gender differences in illness behaviour
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
Discuss gender differences in oral health
```
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
Discuss eating and mental disorders F are more likely to suffer from and their dental impact
Eating
- anorexia, bulimia
- dental erosion
Mental
- stress, depression
- atypical facial pain
- temporomandibular disorders (3x as likely)
93
Discuss reasons for gender differences in health behaviour
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
Define health behaviour and health attitudes
Behaviour: actions taken by healthy person to enhance/maintain health
Attitude: individuals' view of obesity, drugs, mental, physical illness etc
95
How do we influence behaviour but why is the behaviour not sustained?
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
Discuss 2 types of conditioning involved in learning theory
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
Discuss the A B C of learning theory
Antecedents
- environmental stimuli associated w/ behaviour
- presence inc. likelihood of behaviour
Behaviour
Consequences
- make behaviour more/less likely to occur in future
98
Explain the types of punishment and reinforcement
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
Discuss shaping conditioning in learning behaviour
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
Discuss social learning theory
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
Give examples of social learning theory
Child and parent interactions
| - children imitate parents' behaviours good and bad
102
Discuss expectancy-value
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
Discuss self-efficacy and factors affecting it
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
Discuss the 5 factor health belief model
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
Discuss the engineering and physiological models of stress
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
Discuss the transactional model of stress
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
Discuss the appraisal steps involved in transactional model of stress
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
Discuss relation b/w stress and body function
Psychoneuroimmunology
- stress -> inc. cortisol -> immunosuppression -> bacteria flourish
- stress -> red. mucosal healing
Functional oral problems; grinding/TMJD
109
How does stress lead to disease?
Behavioural and physiological changes
110
Discuss behavioural changes associated w/ stress
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
Discuss the physiological changes seen in stress
Cortisol suppresses immune system
IL-1 dec. by 60% during exam period (Marucha et al, 1996)
112
What dental problems are associated w/ stress?
```
TMJD
Bruxism
Canker sores
Dry mouth
Burning mouth syndrome
Lichen planus
Gum disease (Croucher et al, 1997)
Caries (Sutton, 1965)
```
113
Define ageing and ageism
Ageing: process of growing old; biomedical and social models
Ageism: stereotyping of and discrimination against someone due to age
114
Compare the biomedical and social models of ageing
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
Discuss common oral health problems in older people
```
Edentulism; improving
Xerostomia; due to polypharmacy
PD disease; common due to irreversible nature
Oral cancer
Root caries
```
116
Discuss the social impact of dental problems for older people
Avoid conversation
Eating difficulties
Not smile
Stay inside if have no teeth/can’t tolerate dentures
117
Discuss the treatment issues seen w/ older people
Older people viewed as less satisfying to teach
Use stereotypes, over simplification
-ve attitudes towards edentulous pt
118
Possible explanations for age differences in oral health
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
Discuss the implication on NHS of oral health problems in old age
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
Distinguish fear, anxiety, phobia
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
4 types of anxiety/fear seen in dentistry
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
Consequences of dental anxiety/phobia
Avoidance/attendance: cancellation, deferring treatment
Complexity/OH: sedation, inc. complexity, longer time,OH deteriorate
Personal: shame, maintenance of anxiety/avoidance
123
Discuss assessment of dental anxiety
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
How is dental anxiety acquired?
Direct exposure; classical condition
Social/vicarious learning
Transmission of info and meaning; operant conditioning
125
Explain how classical conditioning can lead to dental anxiety
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
Evidence for classical conditioning in dental anxiety and limitations
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
Explain how vicarious learning and transmission of info and meaning can cause dental fear acquisition
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
Explain how operant conditioning plays role in development and maintenance of dental anxiety/phobia
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
Pathway to extinguish dental anxiety
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
Chair side techniques for extinguishing anxiety
Non-relaxation: communication, distraction
Quasi-relaxation: guided imagery
Relaxation: progressive muscle relaxation
131
Discuss management of low level anxiety pt in practice
Children
- rapport
- voice control
- distraction
- modelling
- memory reconstruction
- environmental changes
Adult
- enhancing sense of control
- cognitive distraction
- environmental changes
132
Discuss management of moderate and severe anxiety pt in practice
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
Define pain
Unpleasant sensory and emotional experience associated w/ actual or potential tissue damage or described in terms of such damage
134
Descartes theory of pain
Specificity theory
Specific degree of pain travels to centre in head
Specific dose equates to specific severity
135
Biological theory of pain
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
Shortcomings of the biological theory of pain
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
Gate theory of pain
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
Dimensions of pain
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
Relationship b/w pain and anxiety
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
Reasons for discrepancies b/w predicted and actual pain
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
4 environmental pain determinants
Context
Predictability
Controllability
Distraction
142
Discuss context as attenuating factor of pain
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
Role of predictability/expectancy in pain perception
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Anderson and Pennebaker 1980
Students place hand in apparatus of vibrating sandpaper
Told
- pleasant
- painful
- nothing
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Neutral and pleasant groups had pleasant experience
Painful group had painful experience
144
Role of distraction in pain perception
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
Effect of perceived control on pain perception
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
Emotional determinants of pain perception
Mowrer’s 2 factor theory: operant conditioning
Davey’s model
Fear-avoidance model
Acceptance-based models
147
Fear avoidance model of pain perception
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
Role of avoidance in pain perception
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
Define placebo effect and possible mechanisms for it in relation to pain
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
How is pain measured?
Subjective
- verbal
— unstructured
— verbal rating scale; mild, mod., severe
- visual/graphic scales; visual analogue scale
Behavioural
Psychological
151
Discuss inc. predictability in relating to coping w/ treatment
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
Discuss inc. control in relation to coping w/ treatment
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
Discuss coping strategies for dealing w/ treatment
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
Discuss presence of parent in relation to children coping w/ treatment
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
Discuss modelling intervention for helping children cope w/ treatment
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
Discuss the combined approach for helping children cope w/ treatment
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
Factors affecting compliance
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
Relationship b/w satisfaction and attendance
Direct
Satisfaction correlated w/ attending preventative checkups and attending dentist in last 6/12
159
6 methods to improving satisfaction and compliance
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Continuity of care: same clinician
Reputation: teaching hospital
Support services: team effort needed
Consultation style
Info for pt: in writing
Pt involvement
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160
Discuss consultation style for improving satisfaction
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
Discuss pt involvement for inc. satisfaction
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
Factors affecting pt recall of info
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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
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