Human Disease Flashcards
When were GAs banned in GDPs?
2000
Name the 3 categories of pateints whom should recieve a GA?
- Situations where it would be impossible to achieve adequate local anaesthesia and complete treatment without pain
- Patients who, because of problems related to age/maturity or disability, are unlikely to allow safe completion of treatment
- Patients in whom long term dental phobia will be induced or prolonged
What is the definition of anaesthesia?
A reversible iatrogenic state characterised by unrousable unconciousness and reflex depression
Unarousable Unconsciousness - IV agents and gaseous agents?
IV:
- propofol
- thiopentone
- ketamine
Gaseous:
- volatile - isoflurane/sevoflurane/desflurane
- NO2
IV anaestehtics - aim? side effects? adverse affects?
Unconsicuosness
Sides:
- loss of airway reflexes
- stop breathing
- depress cardiac function
Adverse:
- death
Volatile anaestehtics - aim? side effects?
Unconsicuosness
Sides:
- loss of airway reflexes
- stop breathing
- depress cardiac function
What is the defintion of reflex depression?
Drugs which cause unconsciousness depress some reflexes
Larger doses of iv or volatile anaesthetic
- greater reflex depression
- more side effects
The degree of reflex depression required will depend on the surgery being performed
Decrease the noxious stimulus (input)
Local anaesthetic nerve block
Analgesic drugs
Decrease the response to stimulus (output)
Local anaesthetic nerve block
Neuromuscular junction (NMJ) blocking agents
Explain the process of a GA?
Preparation
- Fasting (6 hrs food, 2 hrs fluid)
- Consent
Induction
-IV or inhalation
Maintenance
- Volatile or continuous IV infusion propofol
- Reflex suppression
Emergence
- Reverse NMJ blockers
- Turn off anaesthetic agent
What is monitored during a GA?
Airway
- Facemask
+/- oropharyngeal/nasopharyngeal airway
- Laryngeal mask airway
- Endotracheal tube
Oral, nasal or tracheostomy
Breathing
- Spontaneous
- Intermittent Positive Pressure Ventilation
- Monitoring- SpO2, gas analysis
Circulation
- Monitoring -HR, BP, ECG
- IV access, fluids
The art of GA - what is included?
Tailoring the anaesthetic to
Patient
Surgery
Pre-operative assessment
Intra-operative care
Post-operative care
Communication
Non-technical skills
Why is dental GA more risky than general GAs?
Shared airway
- Competing for same space
- Airway soiling (blood/saliva)
- Laryngospasm
Anxious patients
- Mask/needle phobias
Significant co-morbidities
- Learning disability
Epilepsy/cardiac anomalies/airway/neck
- Blood borne diseases
Solutions to a shared airway?
Nasal mask - patient exhales at you
Laryngeal mask airway - takes up a lot of room in operative field
Nasal endotracheal tube - more technique sensitive and needs more drugs - higher risk for failure
Trachestomy - highest risk - but best outcome
Whom should recieve conscious sedation?
Should be considered in preference to GA
What is conscious sedation?
Patient remains conscious and is able to both understand and respond to verbal commands either alone or accompanied by a light tactile stimulus
Very difficult to achieve!
Easily becomes rousable but unconscious, and is a small step away from GA without airway control.
Requires equipment, training, assistance and close monitoring of patient and clear understanding of risks
Usually in combination with local anaesthesia
Drugs for conscious sedation? - Benzos, IVs and gaseous?
Benzodiazepines
- Oral temazepam/diazepam
- IV midazolam
- Transmucosal
Intravenous anaesthetic agents
- Propofol
Intravenous opiods
- Fentanyl
Gaseous
- Volatile anaesthetics
Isoflurane/sevoflurane/desflurane
- Nitrous oxide in oxygen
Antidotes for conscious sedation drugs - Benzos, Opiates? Propofol and NO?
Benzodiazepines
- Flumazenil
Opiates
- Naloxone
Propofol, ketamine
- No antidote
Nitrous oxide, volatile anaesthetics
- No antidote
Describe the process of conscious sedation?
Consent for treatment
- Children, Mental Capacity Act
Environment/equipment
- Pulse oximetry, BP
Team/ training
- Basic Life Support, critical incidents
Recovery, discharge, aftercare
Clinical governance/ audit/ incident reporting
Name the risks of conscious sedation
Oversedation
Loss of airway
Respiratory depression
Vomiting and aspiration
Idiosyncratic reactions
Delayed recovery
Describe the basic technqiues and process for conscious sedation?
IV midazolam
Inhalational with nitrous oxide/oxygen
Oral / transmucosal benzodiazepine
Only nitrous/oxygen is considered basic in children under 12
Require training
- Must have competence in IV techniques to perform ANY basic technique
Monitoring
- BP, pulse oximetry
Operator sedationist with dental nurse assistant
Describe the advanced technqiues and process for conscious sedation?
Any form of conscious sedation for patients under the age of 12 years (other than nitrous oxide/oxygen inhalation sedation)
Benzodiazepine + any other intravenous agent for example: opioid, propofol, ketamine
Propofol either alone or with any other agent for example: benzodiazepine, opioid, ketamine
Inhalational sedation using any agent other than nitrous oxide / oxygen alone
Combined (non-sequential) routes for example: intravenous + inhalational agent (except for the use of nitrous oxide / oxygen during cannulation)
Require a lot more training
Rescue
- Airway competencies (basic airway manoeuvres, airway adjuncts and the ability to administer positive pressure ventilation) are mandatory
Monitoring
- BP, pulse oximetry, capnography
Separate sedationist
Team must have “immediate access to the equivalent range of skills and facilities to be found in an NHS Acute Trust”
Advanced paediatric sedation
- Even more training
What was included in the Poswillo Report 1990?
Avoid general anaesthesia where possible
Same standards of monitoring, personnel and equipment should apply whether anaesthetic is delivered in hospital or dental surgery
Standards of resuscitation training set
Dental surgeries should be inspected and registered
Role of the general dental practitioner when suggesting anaesthesia?
Need to be aware of
- Risks of GA
- Alternatives to GA
- Process of care for GA
Patient selection
Patient preparation
Consent
ASA classification of a patient?
I Normal healthy patient
II Patient with mild systemic disease
III Patient with severe systemic disease that limits activity
IV Patient with severe incapacitating systemic disease (constant threat to life)
V Moribund patient with poor survival prognosis (< 24 hours)
Risk of death due to GA, in accordance to ASA classifcation of patient?
ASA 1 - 0.4 per 100,000
ASA 2 - 5 per 100,000
ASA 3 - 27 per 100,000
ASA 4 - 55 per 100,000
Name the 5 categories for death under GA and their examples?
Airway
- Failed intubation
Anaphylaxis
- Neuromuscular blocking agents/Latex/Antibiotics
Underlying disease process
- Known/unknown
- Cardiac, respiratory, vascular, neurological, malignant hyperpyrexia
Complications
- Aspiration
Iatrogenic
- Injury/error/equipment failure
What conditions give severe morbidity due to GA?
Cervical spinal cord injury
- Very elderly, atlanto-axial subluxation
Hypoxic brain injury
- Airway, breathing, BP
MI
Stroke
Everything that can cause death
How can the dentist minimise risk for the patient for a GA?
History
- Medical, drug, allergy, previous anaesthetics, family, social
Examination
- Particularly airway, respiratory, cardiovascular
Investigation
Most of this can be done by GP or anaesthetic pre-assessment clinic if the dental practitioner recognises the risks at the time of referral
Identification of risk factors before referral
Is GA really the best option?
Knowledge of particular patterns of disease
- Downs syndrome, cerebral palsy, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis…..
Appropriate referral pathway for procedure?
Name 6 airway conditions that may contraindicate GA?
Obesity/sleep apnoea
Current head/neck pathology
Previous surgery/radiotherapy/burns
TMJ dysfunction
Nasal obstruction
Gastro-oesophageal reflux
What to include for an airway examination before GA procedure?
Thyromental distance
- <6cm
Neck movement
Jaw subluxation
Malampatti score
Inter-incisor distance
- <3cm
Teeth
- Over-bite, crowded mouth
Name and 3 classess of jaw subluxation?
Class A
Class B
Class C
Describe class A jaw subluxation?
lower inciosrs can be protruded anterior to the upper incisors
Describe class B jaw subluxation?
lower inciosrs can be brought edge to edge with the upper incisors
Describe class C jaw subluxation?
lower inciosrs can’t be brought edge to edge with the upper incisors
Name the 4 mallampatti scores?
I - soft palate, uvula and pillars visible
II - soft palate and base of uvula visible
III - only soft palate visible
IV - only hard palate visible
Which patients need and don’t need a GA?
For some ASA 1 anxious patients GA is the obvious choice
For some with severe co-morbidity, GA will be too risky
For some GA is necessary, but level of risk may require change in treatment plan
Dental clearance instead of restorative treatment
Discuss if unsure
What occurs for adult pre-assessment on day of GA?
Anaesthetic pre-assessment clinic
See nurse at ARI, 30 mins appt
- No concerns -> listed for surgery
- Concerns -> anaesthetist reviews notes ->
- Listed for surgery or
- Further investigation (another OP appointment) and/or
- Review by anaesthetist at pre-assessment clinic
Recommend day-case or in-patient care
Expected schedule for a day-case GA?
Arrive 07.30 (or 11.00)
Fast from:
- Midnight (for am cases)
- 06.00 (for pm cases)
- Actual requirements 6 hours food, 2 hours clear fluids
Nurses complete admission paperwork
Dentist and anaesthetist will review before list starts
May be up to 12 patients/day
- Someone has to be last on list!
Occasionally patients are cancelled on day of surgery
What is the day case discharge criteria?
Normally nurse-led
Must wait a few hours post-op
Eat/drink/pass urine
Pain, nausea & vomiting controlled
Live within 1 hour of hospital
Responsible person to accompany them home & stay overnight
Failure may result in overnight stay
What occurs for in-patient GA?
Surgical, medical or social reasons
Post +/- pre-op overnight stay
Multiple days off work/education
What occurs for paediatric GA?
Mainly day-case
- Inpatient care very rare for paeds dental cases
Parent/guardian must attend
Process varies widely
- Know your local hospital
- Surgical department or separate dental suite
- Staggered vs start of list admission times
- Direct to dental suite or day case unit admission
Fasting
- 6hrs food/4hrs breast milk/2 hours fluids
If pre-med required, at least half day
What occurs for special needs GA?
Paeds or adult
Very variable process
Often complex medical risks
Balanced against holistic concerns
Can be extremely challenging to strike right balance
Meticulous assessment and planning required
Combining multiple procedures under GA
- Better for patient
- Very difficult to arrange
How is a patient prepared before a GA?
What will happen after referral?
What will happen on the day?
Requires knowledge of process of care
- Paediatric
- General adult
- Dental anxiety
- Special needs
- Beware disease patterns
How is consent achieved for GA?
Process should start with general dental practitioner
Requires capacity and competence
- Adults with incapacity
Adult/special needs/child
Competence
- Scottish and English Law differ
What is the defintiion of the Bolam test?
doctor’s conduct would be supported by a responsible body of medical opinion, no longer applies to the issue of consent.
The 3 questions to think about when assessing whther the patient can consent effectively?
Does the patient know about the material risks of the treatment I am proposing?
Does the patient know about reasonable alternatives to this treatment?
Have I taken reasonable care to ensure that the patient actually knows this?
What questions should you ask for history of a swelling?
Onset, course duration
Painful or painless
Other lumps
Effect on general condition
Cause
Does the lump disappear
What types of onset describe swelling?
Gradual - benign
Rapid - inflamatory
Acute - bleeding into cyst
Accidental - ?
Incidental - during clinical exam
History of swelling - duration?
Malignancy is unlikely with long time
Recent changes to the lump, can show malignancy
How long?
History of swelling - painless or painful?
Painless
- most lumps
Painful
- traumatic
- malignant but only late (indicate infiltration if local nevres and surrounding structures
History of swelling - other lumps?
Other lumps anywhere else?
History of lump - effect on general condition (different types of lumps)
Benign/early malignant lump
- no effect
Inflammatory lumps
- symptomatic
Malignant lumps
- weight loss and
History is swelling - cause?
Trauma
Previous surgery
History is swelling - does the lump disappear?
If it disappears, its a hernia
How to exam a swelling?
A general exam:
- overall person condition
Local exam:
- inspection
- palpation
- percussion
- auscultation
How to describe the inspection of a swelling?
Site - specific (near structures)
Size
Shape
Surface (smooth or irregular
Skin overlying (normal, inflamed, scars or dilated veins)
Dilated veins? Main differential diagnosis
Degree of venous obstruction
Special signs that indicate to a specific diagnosis?
Movement with swallowing:
- seen in thyroid swellings
Movement with protrusion of the tongue:
- seen in thyroglossal cyst
Pulsations:
- seen in swellings related to arteries
- aneurysm (dilated artery)
Cough impulse:
- seen in hernia
How many Ss for swelling inspection?
6
Site
Size
Shape
Surface
Skin overlying
Special signs
Palpation - what are key to conducting a palpation?
Firstly, ask if anything is painful and if anything becomes painful tell me
Comparison of temperature of skin and the swelling (= increased vascularisation or inflammation)
Size
Surface: smooth or irrevular
Edge: Well defined or ill defined (cancer)
Consistency: cystic or sold
Relation to surrounding structures:
- skin
- muscles
- arteries and others
Draining lymph nodes* - enlarged lymph nodes (= metastasis or inflammatory)
Special signs
Palpation - consistency - what to look for?
Cystic:
- fluid containing swelling
- positive cross fluctuation in 2 perpendicular directions
- watching and displacing finger
Solid: doesn’t contain fluid
- soft (ear lobe)
- firm (ear cartilage)
- hard (forehead)
- indurated (nose cartilage - malignancy)
Palpation - relation to surrounding structures - skin?
Is the lump separate from overlying skin?
- pinch skin over lump
Lump tethered to the skin?
- lump can move with range
Lump fixed to the skin?
- lump and skin move together (= cancerous)
Palpation - relation to surrounding structures - muscles?
Superficial to the muscle
- more prominent on contraction
Deep to the muscle
- not felt on contraction
Inside the muscle
- less prominent and fixed when contracting
SCM - push against face to opposing sides
Special signs - transillumination?
Shine a light through a swelling - must be clear liquid and so also must be cystic
Lymphatic hygroma
What is auscultation?
Listening over the swelling to decide whether cystic
What is a stoma?
An artificial opening made into the surface of the body leading to the gut
Name the 2 types of stoma?
Ileostomy - small bowel (4/5 changes) above the skin
Colostomy - small intestine (1change) flush with the skin
What isnthe function of the nasogastric tube?
To prevent vomiting and aspiration
Allows decompression of stomach and small bowel
Large pore tube
How to achieve nutritional support for a patient
Enteral feeding tube
- fine pore NG tube
How to achieve nutritional support for a patient without access to the oesophagus?
PEG tube
- percutaneous endoscopic gastrostomy
How to achieve nutritional support for a patient with no stomach?
Jejumostomy tube
How to achieve nutritional support for a patient that can be fed eneterally?
Parenteral feeding
- total parenteral nutrition
Name generic urinary catheter?
Foley’s catheter
Catheter for non-urethra possible?
Drains?
Blood
Bile
Fluid
Chest drain? Why?
Remove blood from chest
Name the 6 sub-specialities of surgery?
Neuro
Cardiothoracic
Urology
Ortho
Plastics
Maxillofacial
Name the 4 sub-categories of a general surgery?
Upper GI - oesophagastric
Lower GI - colorectal
HBP - hepatic, biliary and pancreatic
Breast - breast
Somatic pain vs visceral pain?
Somatic:
- sharp
- more severe
- localised
Visceral:
- vague
- not localised
- less severe
Rationale of minimally invasive surgery?
Smaller access size
No compromise on surgical success
Reduction of trauma of access
How to improve surgical vision?
CO2 pumped into abdomen to increase SA and allow better visual
Benefits (5) of minimally invasive surgery?
Less scarring
Less pain
Faster recovery
Shorter hospital stay
Quicker return to normal activity
Limitations of the laproscopic camera?
Camera controlled by assistant
2D image for 3D idea
Limited retraction
Limited dexterity
Limited to do higher precision tasks
Advantages of robotics?
Camera controlled by surgeon
Better magnification
More movement
3D
Cardiovascular risk for patient with pregnancy?
Increased pulse but lower BP
Increase of 40% of plasma volume
Possible fainting and palpitations
Gastrointestinal risk for a pregnant patient?
Decreased oesophageal pressure
Decreased gastric emptying
Decreased gastrointestinal motility
Nausea and vomiting
Heartburn
Constipation
Musculoskeletal risk for the pregnant patient?
Change in posture - sciatica pain
Relaxation of pelvic joints
Back pain
Pelvic girdle pain
Respiratory risk for pregnant patient?
Decreased total lung capacity, but tidal volume increases
SoB
Problem with GA as less time for intubation - swollen larynx and pharynx
Urinary risk for a pregnant patient?
Right sided hydronephrosis, with increased urinary stasis
Increased urinary frequency
UTI increases preterm births
Haemoglobin risk for pregnant patient?
Thrombophillic state, a fall in haemoglobin
Increased risk of DVT/PE and anaemia
Useful medications to aid with haem for pregnant patients?
Aspirin to reduce risk of pre eclampsia and improves placental function
Doltaparin - blood thinner
Drugs for nausea and vomiting?
Anti-emetics - cyclazine
Drugs for stomach?
Omeprazole
Name the common dental conditions in pregnancy?
Pregnancy gingivitis
- increased inflammation
- increased bleeding
- worst in 3rd trimester
Benign oral growth lesions
- 5% of pregnancies
Tooth erosion/dental caries
- increased acidity in the mouth
- secondary to vomiting
Increased tooth mobility
Name the 3 clinical considerations for pregnancy and dental procedures?
Inferior vena cava compression
Airway oedema
Breast enlargement
Ensure patient lies on the left side to avoid vessel compression (pack a pillow down the side)
Drug for heartburn?
Ondansetron
If patient has collapsed, and patient is in late term pregnancy, what should you do?
Deliver
Resuscitation is impossible as bump is very large
Periods of fatal development?
CNS - 3 weeks to full term
Ears - 4 1/2 to 20
Teeth - 6 3/4 to full term
Palate - 6 3/4 to 16
Upper limbs - 4 1/2 to 9
External genitalia - 7 to full term
Lower limbs - 4 1/2 to 9
Heart - 3 1/2 to 9
Eyes - 4 1/2 to full term
Valproate - never in pregnancy? Why?
Valproate
- epilepsy
- folate antagonist
- assoc with neural tube defect
- ideally avoid in women of child bearing age or change to another drug pre pregnancy
Spina bifida
Tetracyclines - never in pregnancy? Why?
Tooth staining
Skeletal developmental problems
Warfarin - never in pregnancy? Why?
Warafrin:
- fetal warfarin syndrome - low birth weight, developmental delay, deafness, hypoplastic nose and skeletal abnormalities
- may need to stay mediscstion due to metal heart valve risk vs benefit
- can be used postnatally
Alcohol - never in pregnancy? Why?
No safe level of alcohol
Fetal alcohol syndrome - developmental delay, behaviour issues, characteristic facial features (thin upper lip, smooth philtrum and decreased eye width)
Name 4 teratogens?
Valproate
Tetracyclines
Warfarin
Alcohol
Is paracetamol safe during pregnancy?
YES
Local anaesthetic in pregnancy?
Lidocaine with adrenaline is not harmful to baby, if in normal doses
Can cause neonatal respiratory depression, hypotonia and bradycardia in large doses
Adrenaline can cause reduction in placental perfusion
Antibiotics in pregnancy?
Penicillin, amoxicillin and metronidazole all safe
Avoid:
- tetracycline - skeletal effects (1st) and tooth discolouration (2nd and 3rd)
- gentamicin (unless patient is very unwell)
- ciprofloxacin (arthropathy)
Painkillers during pregnancy?
Paracetamol safe
NSAIDs - avoided in 3rd trimester as can cause ductus arteriosus
Dihydrocodiene - small risk of neonatal respiratory depression
Common drugs to consider for pregnancy? That are very good for pregnancy
Aspirin - reduces the risk of a small baby and hypertensive disorders
Heparin - reduces the risk of DVT/PE
X-ray risk for pregnant patient?
Commonest teratogenic effect of radiation:
- microcephalic with several mental regards option
- main effect between 10-17 weeks
- very little risks before 10 and after 27
Threshold dose:
- >250 mGy 0.1% risk
- >1000 mGy microencephaly, growth restriction, genital and skeletal malformation
Does dental health affect pregnancy?
More linked to socioeconomic status
- and that’s why poor dental hygiene was linked
Name the 7 principles of palliative care?
Focus on QoL
Whole person holistic approach good symptom control
Care of patient and family as a unit
Respect for patient autonomy
Emphasis on sensitive/open communication
Affirms life and regards digs as normal
Name the 4 categories of palliative care?
Physical
Psychological
Spiritual
Social
What tool to use to score a patients deterioration?
Supportive and Palliatice care indicators tool (SPICT)
Common symptoms for palliative patients?
Pain
Nausea
Vomiting
Respiratory secretions
SoB
Anxiety
Agitation
Constipation
Fatigue
Anorexia
Oral thrush
What medications can be prescribed for palliative care?
Opoids - morphine
Anxiolytics - midazolam
Antiemetic - levomepromazine
Antisecretory - hyoscine butylbromide
What is included for end of life care?
Individualised
Comfort
Symptom control
Communication
Hydration
Anticipatory mess
Psychosocial support for patient and relative
When should specialist palliative care be advised?
Complex symptoms control
End of life care
Rehabilitation
How to aid planning for palliative care?
Palliative and supportive care plan 2017
Place of care and death
Treatment they don’t want
What is the definition of palliative care?
Care for people living with a terminal illness where a cure is no longer possible
Also for people with complex illness and need their symptoms controlled
What is the defintion of dental palliative care?
Holistic approach
Relief from pain
Team approach
Palliative care alongside treatments
5 factors for oral health in palliative care?
QoL
Communication
Facial appearance
Drinking
Eating
Optimum oral health characteristics?
Normal and intact immunity
Normal saliva production
Intact mucosa
Oral problems in palliative care?
Aetiology of painful mouth?
Generalised:
- candidiasis
- mucositis
Localised:
- tumour
- aphthous ulcers
- herpes simplex or zoster
- dental
General advice for all patients for dry mouth?
Mouth and lips clean most and intact from plaque
Maintain fluid intake
Water based gel to dry lips
Reduce sugary foods and drinks
Name 11 causes for devteased saliva production?
Rheumatoid conditions
Primary biliary cirrhosis
Pancreatic insufficiency
HIV/AIDS
Cystic Fibrosis
Stroke
Anxiety/Depression
Ageing
Chemotherapy
Radiotherapy
Drugs
Describe the Challacombe Scale for oral dryness?
Scale of 1-10 of how severe the oral dryness is
1-3 is mild - no treatment necessary, advise sugar free chewing gum and regular hydration
4-6 is moderate - sugar free chewing gum or sialogogues prescribed saliva substitutes and fluoride may be indicated, investigate into the cause.
7-10 is severe - saliva substitute and fluoride necessary, need to identify cause and eliminate Sjogrens if possible. Patient needs regular monitoring.
Challacombe scale grade 1?
Mirror sticks to mucosa
Challacombe scale grade 2?
Mirror sticks to tongue
Challacombe scale grade 3?
Frothy saliva
Challacombe scale grade 4?
No saliva pooling in floor of mouth
Challacombe scale grade 5?
Tongue shows generalised shortened papillae
Challacombe scale grade 6?
Altered gingival architecture (smooth)
Challacombe scale grade 7?
Glassy appearance of oral mucosa, especially palate
Challacombe scale grade 8?
Tongue lobulated or fissured
Challacombe scale grade 9?
Cervical caries in more than 2 teeth
Challacombe scale grade 10?
Debris on palate or sticking to teeth
Name the 8 effects of xerostomia?
Dental caries
Gingivitis
Halitosis
Altered taste
Candiadisis
Mouth ulcers
Fissuring of tongue
Chewonf difficulties
Describe saliva composition?
99% water
1% - mucin, electrolytes, enzymes and proteins
Name the 7 functions of water in saliva?
Lubrication
Cleansing
Taste
Speech
Food prep
Mucosal protection
Name the 3 functions of mucin in saliva?
Lubrication
Mucosal protection
Food prep
Name the functions of enzymes in saliva?
Digestion
Name the functions of proteins in saliva?
Antimicrobial
Name the 2 functions of electrolytes in saliva?
Buffering
Mucosal protection
Describe the 9 options for dry mouth management
Treat underlying cause
Review meds
Good OH
Dietary advice
Regular check ups
Regular sips of water
Lubricate lips
Saliva substitutes
Saliva stimulants
Name 4 saliva stimulants?
Pilocarpine
Chewing gum - sugar free
Organic acids - salivix pastilles
Acupuncture?
Name 5 saliva substitutes?
Water
Glandosane
Saliva orthana lozenges or spray
Biotene oralbalance saliva replacement gel
BioXtra gel
Describe orthana saliva spray?
Mucon-containing saliva substitutes porcine derivative
Describe glandosane?
Low pH can damage teeth
What is the defintion of oral mucositis?
Affects people who are recieving radio or chemo
Affects 85-100% of H and N patients
2 in 3 patients with mucositis will need a lowered dose or hospitalisation
How to manage mucositis?
Analgesia
Mouth rinse
Mucosal protectant
Systemic therapies
What analgesia can be used for mucositis?
Increases protection
Decrease inflammation
- benzydamine mouthwash
- benzydamine oromucosal spray
Analgesia
- topical
- systemic
How to use chlorhexidine gluconate 0.2% mouthwash
Can be diluted 1:1 with water
Name other types of mouthwash for mucositis?
Tea tree mouth wash
Caphasol mouth rinse
How to use gelclair mucosal protectant?
Forms a protective coating
A gel for lesion
oropharyngeal cavity
Provides pain relief
Name a systemic therapy for mucositis?
Folinic acid (gives as calcium folinate)
Used to counteract the folate antagonist action of methotrexate
Palifermin - an IV injection containing human keratinocyte growth factor indicates for the management of oral mucositis
Name 6 causes of painful mouth?
Trauma - sharp teeth
Haematinic deficiency
Viral infection (herpes simplex)
Aphthpus ulceration
Oral malignancy
Mucositis
What other treatments for mucositis?
Milder toothpastes
High dose fluoride
What other side effects of radiotherapy?
Mucositis
Oral ulceration
Radiation caries
Oral infection risk for cancer patients?
Fungal
Viral
Bacterial
Side effects of cancer treatment, oral relation?
Taste disturbance
Xerostomia
MRONJ
What is the definition of multimorbidity?
coexistence of two or more chronic conditions
How does multimorbidity affect care?
major impact on quality of life, increased risk of mortality, and places significant financial costs to the health and social care system
Common multimorbiditiy diseases?
diabetes, multiple drug interactions, cardiac abnormalities, and infectious disease.
What is the role of Special Care Dentistry?
The improvement of oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors
What is the acronym RSVP?
Recency - recent events (hospital) acute medical episodes
Systemic symptoms - pain or breathlessness
Vital signs - C, BP, RR, HR
Prescription drugs - Interactions
How to determine the patient’s quality of life?
Quality of Life
- living with chronic pain / disability : depression
- dependant on medication + carers
What are they looking for?
- oral health not high priority: pain relief, appearance (Serban 2019)
- communication and trust (Cumella 2000)
What systems to group meds into?
Cardiac
Respiratory
CNS
Endocrine
Everything else
What to think about when looking at patient’s meds list?
Recognise conditions + severity
Adverse medical events
Bleeding + healing issues
LA / IVS issues
Dental prescribing : interactions
Prevention: xerostomia
Red flags
A general rule of thumb for patient’s medication?
when risk assessing the severity of the disease or weighing up how stable the condition can broadly be deduced by the number of drugs that a patient is taking for the condition.
Describe the increasing severity of HBP, with medications?
bendroflumethiazide - Mild
Bendro with Ramipril - Mod
Bendro with Ramipril with amlodipine - severe
Cardiac patient’s main causes for referral to SCD?
unstable angina
pre cardiac surgery
At what ASA level must a patient ne referred to a hospital setting?
Patients with an ASA status of 3 and above are to be treated in a safer hospital care setting often under the supervision of a specialty or consultant anaesthetist who use a more sophisticated cardiac pre-operative risk assessment
Name immunosuppressed patient 2 medications and 4 side effects?
Cancer
Chemo
Radio
Methotrexate
These patient’s need screening of their conditions to allow them to receive the best treatment
Steroids
- Prednisolone , Dexamethasone
Side effects
- Osteoporosis, Diabetes, Hypertension
- Mood changes, weight gain, gastric ulceration, adrenal suppression
Name 4 common meds for a transplant patient?
Steroids
Azothioprine
Ciclosporin
Tactolimus
Name 7 other commonly referred patients to SCD?
Respiratory Disease
Liver Disease
Renal disease
Diabetes
Epilepsy
Congenital Bleeding Disorders
Rheumatoid Arthritis
What is the definiton of a hypersensitivity reaction?
A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign agent
What is the defintion of an allergy?
response by the immune system to an otherwise innocuous antigen
What is the summary for type I hypersensitivity?
Immediate hypersensitivity
IgE mediated
Anaphylaxis - Urtcaria
What is the summary for type II hypersensitivity
Cytotoxic hypersensitivity
IgG or IgM mediated
Drug induced thrombocytopenia
What is the summary for type III hypersensitivity
Immune complex mediated hypersensitivity
Antigen-antibody immune complex
Serum sickness
Vasculitis
What is the summary for type IV hypersensitivity
Delayed hypersensitivity
T cell mediated
Contact dermatitis
Name the 5 symptoms of TI hypersensitivity?
Urticaria
Angioedema
Bronchoconstriction
Allergic rhinitis/conjunctivitis
Anaphylaxis
Explain Latex allergy MoA?
TI or TIV
If type 1 allergy
- Most problems from skin or mucous membrane contact with latex
Banana, kiwi, chestnut, avocado, pineapple, passion fruit, apricot, and grape
What allergen test to do for a TI and TIV reaction?
Type 1 allergy
- Serum specific IgE levels
- High rate of false positive results if atopic
- Skin prick tests
- Challenge testing
Type 4 allergy
- Patch testing
Name the 16 dental allergens?
5 Acrylates
5 metal salt compounds (mercury, golds, palladium,platinum)
2 resin chemicals
Flavouring (eugenol, peppermint)
Activators/curing agents(Benzoyl peroxide, hydroquinone)
Name some other rare allergens in dentistry?
Preservatives (formaldehyde, sodium metabisuphite, methylisothiazolinone)
Steroids
Rubber accelerators
Local anaesthetic reactions (type 1 or 4)
What is the defintion if a macule?
Non-palpable change in skin color with distinct borders
What is the defintion of a patch?
Non-palpable change in skin color with distinct borders
What is a papule?
Palpable, solid lesion less than 1 cm in diameter
What is a plaque (skin)?
Palpable, solid lesion greater than 1 cm in diameter
What is a nodule?
Palpable, lesion more than 1 cm in diameter which is taller than it is wide
What is a vesicle?
Fluid-containing, superficial, thin-walled cavity less than 1 cm
What is a bulla?
Fluid-containing ,superficial, thin-walled cavity greater than 1 cm
What is erosion?
skin defect where there has been loss of the epidermis only
What is an ulcer?
A skin defect where there has been loss of the epidermis and dermis
What is a pustule?
Pus containing, superficial, thin-walled cavity
What is an abscess?
Thick-walled cavity containing pus
What is paraneoplastic pemphigus associated with (cancer)?
NHL
CLL
Discriminatory sign is intractable stomatitis
What is the defintion of bullous pemiphigoid?
Again common in the elderly
Widespread pruritic eruption
Tense bullae seen
How to diagnose, test and treag for immunobullous disease?
Consider diagnosis in non-resolving stomatitis in Elderly patients
Diagnosis is made by biopsy of mucosa or skin adjacent to the ulcer/erosion
Sent for direct immunofluorescence (DIF)
Treatment is immunosuppression
high dose oral corticosteroids
What is the deifntion of skin related erythema multiforme?
Acute self–limiting, but may be recurrent
Abrupt onset of target lesions ~ 24hrs
Favours acrofacial sites
EM minor – target lesions with little/no mucosal involvement
EM major – target lesions with severe mucosal involvement and systemic symptoms
Predominantly young adults
What is the aetiology for erythema multiforme?
Commonly associated with infection (90%)
- Viral: HSV, orf, EBV, CMV, viral hepatitis, adenovirus
- Bacterial: Mycoplasma, salmonella, mycobacterial
- Fungal: Histoplasmosis, dermatophytes
Other 10%
- Drugs, systemic diseases (SLE, IBD), poison
What is the treatment for erythema multiforme?
Treat precipitating cause
Supportive care
Topical anaesthetic and antiseptic rinses
Meticulous eye care if needed
Short course oral steroid if severe
If due to HSV and recurrent episodes
Consider long term antiviral treatment
If not due to HSV and recurrent
Consider dapsone or immunosuppressant
Name the 7 forms of oral lichen planus?
Atrophic
bullous
Erosive
papular
pigmented
plaque like
Reticular
Name some oral lichenoid reaction materials?
Amalgam, composite/resin based materials
Porcelain, glass ionomer cement,
Cobalt, gold, nickel, palladium, titanium
Cinnamon, eugenol, menthol, peppermint, vanilin
What is the defintion of orofacial granulomatosis?
Persistent, non-tender swelling of the lip and or face
Non-caseating granulomatous inflammation
Usually only upper or lower lip is affected
Some think it is a food or additive hypersensitivity reaction
May be a sign of underlying crohns disease or sarcoidosis
What is the defintion/aetiology of angular cheilitis?
Drooling (age related, neurological issue)
Irritant contact dermatitis
Dry lips/environmental
Deep Marionette lines
Infection (bacterial, fungal, viral)
Medication
Poor nutrition
What is the definition of perioral dermatitis?
Tender or itchy papules around the mouth
Unaffected zone around lips
Rebounds after topical steroids
Can also get periorbital dermatitis
Treat by stopping everything
Topical or oral antibiotic may be needed
If severe topical tacrolimus or oral retinoid
Name 6 benign skin lesions?
Seborrhoeic keratoses
Viral warts
Cysts
Dermatofibroma
Lipoma
Vascular lesions
Name 3 premalignant skin lesions?
Bowens disease
Actinic Keratoses
Melanoma in situ
What is the defintion of a seborrheoic keratoses?
Benign, but commonly referred
Warty growths, “stuck on appearance”
Patients often have multiple +/- cherry angiomas
Generally left untreated, but if troublesome
- Cryotherapy
- Curettage
Pros and cons of cryotherapy?
Liquid nitrogen
Pros
Cheap
Easy to perform “on the day”
Cons
Can scar
Failure/Recurrence
No pathology result
What is the definition of Leser-Trelat?
Paraneoplastic phenomenon
Abrupt onset of widespread seborrhoeic keratosis, particularly in a younger individual
Premaliganncy for GI adenocarcinoma
What is the defintion of a viral wart?
Due to Human Papilloma Virus
Rough hyperkeratotic
Will clear when immunity developed to virus
Cryotherapy or wart paints can stimulate immune system slightly
Can curette in severe cases
What is the defintion of a cyst?
Encapsulated lesion containing fluid or semi-fluid material
Usually firm and fluctuant
Multiple different types of cyst exist
What ks the treatment for cysts?
Can rupture and cause inflammation of surround skin
May become secondary infected
Treated with excision
If inflammed/infected
Antibiotics
Intralesional steroid
What is the defintion of dermatofibroma?
Benign fibrous nodule, often on limbs
Proliferation of fibroblasts
Cause is unknown.
attributed to an area of trauma.
Firm nodule, tethered to skin but mobile over fat. Pale pink/brown. Often paler in centre.
Dimple sign positive
Usually asymptomatic. Can be itchy or tender
Excision if concern or symptomatic.
What is the defintion of a fibroma?
Benign tumour consisting of fat cells
Common
Cause unknown
Smooth and rubbery subcutaneous mass
Usually asymptomatic
If tender
?angiolipoma
?Liposarcoma – rare malignancy
Name 2 vascular lesions?
Angioma
Pyogenic granuloma
What is the definfion of an angioma?
Overgrowth of blood vessels in the skin due to proliferating endothelial cells
Generally asymptomatic. Can be unsightly or bleed
Pregnancy & liver disease
Excision or laser
What is the defintion of a pyogenic granuloma?
Rapidly enlarging red/raw growth, often at a site of trauma.
Bleed easily
Cause is unknown
Occur in up to 5% of pregnancies
Common on head and hands
Removed by curettage & cautery
What is the defintion of Bowen’s disease?
Rapidly enlarging red/raw growth, often at a site of trauma.
Bleed easily
Cause is unknown
Occur in up to 5% of pregnancies
Common on head and hands
Removed by curettage & cautery
Treat Bowen’s disease?
Cryotherapy
Curettage
Lesion scraped off and heat applied to seal vessels and destroy residual cancer cells
What is the defintion of photodynamic therapy?
Photochemical reaction to selectively destroy cancer cells
Topical photosensitising agent applied
Concentrates in cancerous cells
Red light applied ( light colour dependant on which agent is used)
Photodymanic reaction occurs between light, photosensitiser and oxygen causing inflamation and destruction of cells
Pros and Cons of photodynamic therapy?
Pros
Done for the patient by hospital staff
Can treat multiple areas, including those which would be hard to reach by patient
1 or 2 treatments
Cons
Requires hospital appointments
Can be painful and scar
Pros and Cons of Imiquimod?
Aldara
Immune response modifier
Stimulates cytokine release
Inflammation and destruction of lesion
Pros
Useful where surgery is undesirable
Usually good cosmetic result
Large surface area
Cons
Treatment time is 6 weeks
Significant inflammation
Failure/recurrence
What is the defintion of melanoma in situ?
Melanoma cells entirely confined to epidermis
No metastatic potential
Treated with excision
Explain how to protect self from Sun?
Cover up
Avoid sun at peak hours
10am-4pm
Don’t burn and try not to tan
Avoid sunbeds
Sunscreen
UVA & UVB protection
At least SPF 30 / 4 Star
Need to apply 2 tablespoons every 2 hours
Name the 7 risk factors for skin cancer?
UV radiation
Photochemotherapy (PUVA)
Chemical carcinogens
Ionising radiation
Human papilloma virus
Familial cancer syndromes
Immunosuppression
What is the defintion of basal cell carcinoma?
Slow growing
Locally invasive
Rarely metastasise
Nodular
Pearly rolled edge
Telangiectasia
Central ulceration
Arborising vessels on dermoscopy
How to treat basal cell carcinoma?
Excision is gold standard
Ellipse, with rim of unaffected skin
Curative if fully excised
Will leave a scar
Curettage in some circumstances
Imiquimod if superficial
Indications for Moh’s surgery?
Indications
Site
Size
Subtype
Poor clinical margin definition
Recurrent
Perineural or perivascular involvement
What is the indication for vismodegib?
Indications
Locally advanced BCC not suitable for surgery or radiotherapy
Metastatic BCC
Selectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)
Can shrinks tumour and heal visible lesions in some
Median progression free survival 9.5 months
Side Effects
- Hair loss, weight loss, altered taste
Muscle spasms, nausea, fatigue
What is the defintion of a squamous cell carcinoma?
Derived from keratinising squamous cells
Usually on sun exposed sites
Can metastasise, up to 16% depending on study
Faster growing, tender, scaly/crusted or fleshy growths
Can ulcerate
What is the treatment for SCC?
Excision
+/- Radiotherapy
Follow up if high risk
Immunosuppressed
>20mm diameter
>4mm depth
Ear, nose, lip, eyelid
Perineural invasion
Poorly differentiated
What is the defintion of keratoacathoma
arient of squamous cell carcinoma
Erupts from hair follicles in sun damaged skin
Grows rapidly, may shrink after a few months and resolve
Surgical excision
Name the 3 risk factors for melanoma?
UV Radiation
Genetic susceptibility- fair skin, red hair, blue eyes and tendency to burn easily
Familial melanoma and melanoma susceptibility genes
ABCDE?
Asymmetry
Border
Colour
Diameter
Evolution
7 point checklist for cancer?
Major features
Change in size
Change in shape
Change in colour
Minor features
Diameter more than 5 mm
Inflammation
Oozing or bleeding
Mild itch or altered sensation
Treatment for melanoma?
Excision
Can you take a radiograph for a pregnant patient?
Yes
Dose from one periapical is approx 0.001 mGy and from an OPT 0.1mGy and maximum dose thought to cause concern is 200mGy (background 50mGy per year and this is possibly higher in Aberdeen!) remember a milligray ( mG or mGy is the absorbed dose)
However, this is an emotive subject and the risks vs the benefits must be discussed with the patient. It is worth mentioning that having 0.001-0.1mGy still carries a risk of less that 1 in 1,000,000 risk of childhood cancer (1). Some prospective mothers might not want to take that risk.
Risk less before 10 weeks and after 27 weeks but because of the “ emotive nature of dental radiography during pregnancy, the patient could be given the option of delaying the radiography”
Why should you avoid Felypressin?
it can cause uterine contractions
Which antibiotics are safe and dangerous for pregnant patients?
Yes, it is safe to prescribe penicillins
Avoid:
- metronidazole
- erythromycin
- tetracycline
- doxycycline
What pain relief to recommend to pregnant patients?
Paracetamol is safe
Avoid:
- NSAIDs
- Aspirin
- Dihydocodiene
- Codiene
What symptoms can a pregnant patient experience at 8 week?
Blood pressure drops:
- fainting risk
Emotional changes
Increased urination
Vominiting
Anaemia
What is Dalteparin?
a low molecular weight heparin anticoagulant
Subcut
Is amalgam safe for pregnant patients?
No, it is best avoided as Mercury can crossthe placenta and has been detected in breast milk
A temporary restoration should be placed instead
Removal of an amalgam filling can carried out under rubber dam and high volume suction
Should Duraphat be precribed for a pregnant patient? and what alternatives are there?
No, due o its alcohol content
Nor 5,000ppm flouire toothpastes as the effects of high fluoride are unknown
2,800ppm is deemed safe but must be spat out after brushing
Fluoirde MW of 225ppm or 900ppm
For lactating/breastfeeding
Why to double check medical history when dealing with pregnant patients?
They may not know they are pregnant, or don’t feel like it is important to tell you
Check history generally
Check for pregnancy gingivitis?
hormonal changes can excaerbate pre exisiting plaque induced gingivitis
Possibly gestational diabetes
Dental symptoms of first trimester?
increase in oestrogen and progesterone seems to coincide with increase in gingival inflammation
Describe how hyperplasia of the gingivae looks and is caused?
Hyperplasia of the gingivae is caused by marked proliferation of capillaries and minimal proliferation of fibroblasts
Clinically it appears as dark red/purple papillae which are fragile, bleed easily.
False pocketing and stagnation also may be a problem
Describe how a pregnancy epulis occurs? and how it looks?
Caused by inflammatory response to local irritation which is modified by hormonal changes
- 3rd month of preg
Mushroom like flattened spherical mass – sessile pedunculated base, protrudes from the gingival margin, in the interproximal space, red to dark blue in colour, bleeds easily with minimum trauma, painless unless it interferes with the occlusion
How to treat a pregnancy epulis?
Treatment – same as for pregnancy. induced gingivitis plus you might consider biopsy if it does not resolve after the birth of the baby.
The use of Chlorhexidine mouthwash is not contraindicated but always remember to warn about taste alterations and staining with prolonged use.
Which antifingals are safe and dangerous during pregnancy?
Amphotericin is safe and nystatin but
Avoid:
- miconazole
- fluconazole
(can transfer to foetus or risk malformations)
Is there a link between periodontal disease and preterm/low birth weight babies?
Preterm= pre-37weeks
Low birth weight < 2,500 g or 5.5lbs
Incidence – over 4 million die within first 4 weeks
Risk factors – young maternal age, drug alcohol and tobacco abuse
Maternal stress, genetics, genito-urinary tract infection
Multiple or assisted pregnancies
Research into interventions is not conclusive
Periodontium = reservoir of gm –ve bac, host response elevated levels of chemical mediators, premature labour
No conclusive evidence
What is hyperemis Gravidarum?
continued vomiting
usually during the first trimester but can be throughout.
causing dehydration (dry mouth), weight loss, electrolyte imbalance and hospitalisation
don’t brush after vomiting
How to treat a patient with erosion due to pregnancy vomiting?
Dress teeth, protecting the exposed enamel
A dentine bonding agent ( ie Seal and Protect ) will aid protection
Consider Delaying RCT and radiographs until after birth if possible
We should consider taking study models to observe wear, gag reflex is exaggerated due to obstruction of oesophagus
How to deal with vena cava compression?
posture, take care when lying the patient flat, consider the left lateral tilt to relieve the compression on the blood vessel, use cushion or use a rolled up towel.
Acyclovir for cold sores?
Minimal absorption to the foetus, but shedding at term may lead to HSV transfer to the baby
When is the best time for dental treatment during pregnancy?
Research and evidence suggests that dental care during pregnancy is safe, effective and recommended. ( best time is second trimester)
Name the 3 main tyoes of inherited coagulation disorders?
Haemophilia A
Haemophilia B
von Willebrand’s disease
Describe Haem A?
Factor VIII
X-linked
female carries can have mild bleeding tendency
Describe Haem B
Factor IX def
X-linked
Describe vWD?
Factor VIII def and reduced platelet adhesion
Dominant inhertance
1 in 100
Describe symptoms of haemophilia?
PEOPLE WITH SEVERE HAEMOPHILIA HAVE FREQUENT BLEEDS INTO MUSCLE AND WEIGHT BEARING JOINTS
MODERATE SUFFERES HAVE A FEW SPONTANEOUS BLEEDS AND IN MILD HAEMOPHILIA THE BLEEDS USUALLY OCCUR AFTER TRAUMA, SURGERY OR DENTAL EXTRACTIONS.
Where do we treat patinets with CBD (congenital bleeding disorders)?
- Majority can be safely treated in mainstream general dental services or via shared care where more invasive or surgical procedures are required.
- Successful management is a result of co-operation between haematologists and dentists.
- No single rigid protocol.
- Each haematological disorder and individual patient requires an individual approach.
What are the management strategies for CBD?
Some dental procedures don’t require augmentation of coagulation factor levels.
Coagulation factor replacement therapy
Release of endogenous Factor stores using desmopressin (DDAVP)
Improving clot stability by antifibrinolytic drugs, e.g. tranexamic acid .
Local Haemostatic measures
LIASON WITH A HAEMATOLOGIST
Wghat is the definition of DDAVP?
Desmopressin
A SYNTHETIC HORMONE, IS A DRUG WHICH IS SOMETIMES PRESCRIBED TO STIMULATE THE RELEASE OF ENDOGENOUS FACTOR STORES.
Describe transexamic acid?
MANAGEMENT STRATEGY TO IMPROVE CLOT STABILITY
What is Haem A and B MoA?
Normal bleeding time and INR but prolonged activated partial thromboplastin time (APTT)
Replacement of the deficient clotting factors - porcine or recombinant by IV infusion
Severe cases : daily injections
15-25% people develop inhibitors or antibodies with repeated use.
Describe the factor replacements and how they should be used?
FACTOR VIII HAS A HALF LIFE OF ONLY 10-12 HOURS AND DENTAL TREATMENT HAS TO BE CARRIED OUT ON DAY OF COVER ALTHOUGH IT IS PREFERABLE, IT IS RARELY POSSIBLE FOR EXTENSIVE DENTAL TREATMENT TO BE COMPLETED IN ONE VISIT, HOWEVER TREATMENT SHOULD BE ORGANISED TO MINIMISE THE NUMBER OF FACTOR REPLACEMENT SESSIONS AND THUS THE LIKELIHOOD OF ANTIBODY DEVELOPMENT
FACTOR IX HAS A LONGER HALF LIFE, ALLOWING DENTAL TREATMENT TO BE CARRIED OUT ON CONSECUTIVE DAYS UNDER A SINGLE DOSE OF REPLACEMENT THERAPY
Describe vWD MoA?
Extended bleeding time due to poor platelet function and low levels of circulating vWF and ristocetin co-factor. 75% have mild or Type 1 vWD
Usually treated with synthetic hormone desmopressin (DDAVP)
Infused IV over 20 minutes at Haemophilia Centre
Can also be self-administered as high strength nasal spray
More severe types require factor replacement therapy derived from human plasma.
Ristocetin co factor
Post OP adivce for CBD?
Severe cases requiring extractions and interventive surgery are usually treated in a safer setting or hospital environment
Some patients are asked to return to the hospital for monitoring.
Tranexamic Acid (TA) Usually administered in tablet form 1g three times a day up to10 days Also available as a syrup or mouthwash in a dental situation
TAILORED WRITTEN AND VERBAL POST-OPERATIVE ADVICE WITH CONTACT TELEPHONE INFORMATION AND AVOIDANCE OF NSAIDS
General principles for factor replacement?
Dental procedures should be performed as close to the time of administration of Factor concentrate as possible.
Factor cover may be prescribed as prophylaxis or on demand.
Expensive - dental treatment should be organised to minimise exposure to Factor replacement therapy.
Blood transfusions before 1986?
Non inactivated replacement factor concentrates from pooled human blood until 1986 when effective heat treatment was introduced.
Risk factor of HIV and vCJD prior 1999
70% patients with haemophilia have presence of HCV
Recombinant (non human derived) factor concentrates in early 1990’s removed the risk of viral or prion transmission
Name the general measure to reduce bl;eding risk?
Minimal trauma
LA with vasoconstrictor
haemostatic agents in sockets
Sutures (resorbable)
Post OP advice
Avoid NSAIDs
How to manage a patient needing emergency treatment with CBD?
Acute pulpitis - pain can usually be controlled by removing pulp from tooth. Temporary dressing until planned extraction
Dental abscess with facial swelling. Antibiotics only if local spread or systemic infection. Seek advice from haemophilia centre
Fractured teeth - normal management +/- cover if significant bleeding soft tissues
Drugss to avoid with CBD?
Aspirin
NSAIDs
CBD considerations for soft tissues?
chlorhex MW
paraffin wax to avoid adherence to mucosa
CBD considerations for resto?
nil
CBD considerations for subging resto?
haemostatic agents - retration cord or transexamic acid
CBD considerations for endo?
sodium hypochlorite irrigation and CaOH paste for bleeding control
CBD considerations for rubber dam?
avoid trauma
CBD considerations for high speed aspiration
avoid trauma
CBD considerations for denture?
care with fitting
soft lining (if needed)
CBD considerations for ortho?
prevention and oral hygiene advice
wax to stop trauma
CBD considerations for routine scaling?
Transexamic acid MW
CBD considerations for perio surgery?
good oral hygiene
factor cover
Mild causes of red eyeness?
Conjunctivitis
• Subconjunctival
haemorrhage
• Dry eyes
• Episcleritis
Moderate acuses of red eyeness?
• Corneal abrasion
• Corneal foreign body
• Iritis (uveitis)
• Scleritis
• Facial nerve palsy
Severe causes of red eyeness?
• Corneal ulcer
(keratitis)
• Penetrating injury
• Chemical injury
• Acute glaucoma
• Orbital cellulitis
Questions to ask when assessing a red eye?
1 eye or 2 eyes affected?
Duration of symptoms?
Discharge?
Do you wear contact lenses?
History of injuries
Previous episodes of something similar?
What treatments have you tried?
Systemically unwell?
How does it feel?
Pain?
Irritated/scratchy/”sand in my eye”
Foreign body sensation
Photophobia – pain in presence of
light (think cornea!)
Has vision been affected?
Appearance of the pupil
Round?
Reactive to light compared to the
other side?
Which eye conditions cause pain?
• Corneal ulcer
(keratitis)
• Penetrating injury
• Chemical injury
• Acute glaucoma
• Orbital cellulitis
• Corneal abrasion
• Corneal foreign
body
• Iritis (uveitis)
• Scleritis
Which eye conditions affect vision?
Conjunctivitis
• Dry eyes
Corneal abrasion
Iritis (uveitis)
Facial nerve palsy
Corneal ulcer
(keratitis)
• Penetrating injury
• Chemical injury
• Acute glaucoma
• Orbital cellulitis
Which eye conditions chnage the apperance of the pupils?
Iritis (uveitis)
Penetrating injury
Acute glaucoma
• Orbital cellulitis
Describe causes of facial nerve palsy?
Inferior alveolar nerve block
• Parotidectomy
How to manage facial nerve palsy?
Tape eye closed
• Generous lubrication
• Optometrist
• Safety net advice
Describe causes of corneal ulcer?
contact lenses
very light sensitive
urgent <24 hrs
foreign bodies - high speed mechanisms
Describe causes of subconjunctival haemorrhage?
asymptomatic
only cancer in trauma
related to HT and anticogulants
Name the 2 forms of conjunctivtis?
bacterial
Viral
Describe bacterial conjunctivitis?
Sticky, purulent discharge
• Bilateral, sequential
• Gritty, uncomfortable
Describe viral conjunctivitis?
Watery, “streaming”
• Bilateral
• Pre-auricular lymphadenopathy
Describe a good history taking for vision loss?
Describe what they can see/not see
Blurry
Distortion
Flashing lights/floaters?
Areas of “missing vision”
Painful? Painless?
Speed of onset
Gradual
Sudden
Other systemic symptoms?
Name possible causes of vision loss?
Cataract
ARMD
Glaucoma
Retinal detachment
Giant cell arteritis
Describe symptoms of cataract?
Common(est?) operation in the world
The lens does not age well!
Leading cause of blindness
Low-middle income countries
Gradual, painless, hazy/misty vision, near/total blindness
Phacoemulsification surgery
Quick, safe, painless, no sutures
Very happy patients!
Describesymptoms of age related macular degeneration?
Age-related macular degeneration
Only central vision affected
Blurred, distorted, holes/gaps, “it’s right in the way!”
Seeing faces, reading
Dry type
Gradual, slowly progressive over many years
No specific treatment
Wet type
Faster onset and progression
Treatable with anti-VEGF injections
Name the 3 types of glaucoma?
Gradual
Chronic
Acute
Describe symptoms of gradual glaucoma?
Condition of the optic nerve (2% >40yrs old)
Gradual, progressive loss of axons from the nerve inside the eye
High pressure is a risk factor
Describe symptoms of chronic glaucoma?
Chronic open angle glaucoma
Peripheral vision affected first, central vision loss is very late
Mostly asymptomatic, painless
Largely treated with pressure-lowering eye drops, life long
Describe symptoms of acute glaucoma?
Acute closed angle glaucoma
Red, painful eye, unreactive pupil, severe headache, unwell patient
Describe the symptoms of retinal detachment?
Flashing light or floaters
shadow in croner of vision
painless
needs urgent surgery < 2 days
no inhalation sedation - causes acute eye pressure rises and permanent sight loss
Describe the symptoms of giant cell arteritis?
Vasculitis, especially branches of external
carotid artery
A true medical emergency
Could present to dentist first
>50 yrs
Jaw/tongue claudication pain
Eating/talking
Tender scalp skin
Headache
Feeling rotten
Losing weight
(Transient) vision disturbance
Name eye related diseases linked with diabetes?
Retinopathy
- vitreous haemorrhage
- retinal detachment
Maculopathy
- retinal oedema
Describe the symptoms of diabetic retinopathy?
Sugary blood damages vessels
Haemorrhages
Oedema (especially at macula!)
Retinal ischaemia
New vessels grow into vitreous (proliferative
retinopathy)
Vitreous haemorrhage
Retinal detachments
Describe the symptoms of orbital fracture?
Bruising
Periorbital oedema
Pain
Double vision
up- and downgaze
Subconj. Haemorrhage
Infraorbital anaesthesia
”Sunken” eye
Why are orbital fractures in children more pertinent to address?
Entrapment more common
“Bend and snap!”
Warrants urgent surgery to prevent
muscle necrosis
Long term double vision if missed
May have little/no outward evidence of
injury
“White eye blow out”
Oculocardiac reflex if muscle entrapped
Slowed heart rate
Nausea/vomiting
Syncope/fainting
What to do in the case of a chemical injury to the eye?
Irrigate, irrigate, irrigate!!!
Tap water, saline, Highland Spring…
Ask questions later
What is it? Give label to patient
Straight to ED
Alkalki worse than acids
Aim = prevent corneal scarring
What is the defintion of Fraility?
A person’s mental and physical resistance, or their ability to bounce back and recover from events like illness and injury
Name the 2 models of fragility?
Phenotype model
Cumulative deficit model
What is the defintion of phenotype model of fraility?
Describes a group of patients characterises which, if present, can predict poorer outcomes
Generally individuals with three or more of the characteristics are siad to have fraility
Characteristics:
- unintentional weight loss
- reduced muscle strength
- reduced gait speed
- self-reported exhaustion
- low energy expenditure
What is the defintion of the cumulative deficit model for fraility?
It assumes an accumulation of deficits ranging from symtpoms to disease which can occur with ageing and which combine to increase the fraility index which in turn increase the risk of an adverse outcome
Symptoms:
- loss of hearing
- low mood
- tumour
Disease:
- dementia
Name the 3 main factors which contribute to fraility?
Disability
Multimorbidity
Biological ageing
What is the defintion of multimorbidity?
Multiple long term conditions
- fraility may be masked due to the focus on their other long term diseases
What are the downfalls in the NHS for fraility?
If patient only has fraility, may be low consumers of health care resources and not regularly known to their GP - until the become bed bound immobile or delirious as a result of minor illness
Multimorbidity can include fraility, but also independent. Many people with fraility with also have disability, and vice versa.
Deacribe the comprehensive geriatric assessment - name the 6 factors?
Physical
Socioecononic/environmental
Functional
Mobility/Balance
Psychological/Mental
Medication review
Why is the comprehensive geriatric assessment successful?
Effective in secondary care:
- reduced mortality
- improved independence for older people
- reducing hospital admission and readmission
- reduced the impact of fraility
- reverse the progression of fraility
Explain the plan created after the comprehensive geriatric assessment
Assessment
Creation of problem list
Personalised care plan
Intervention
Regular planned view
How does ageism have an affect on the elderly
Associated with poorer physical and mental health
Increased social isolation and loneliness
Increased depression
Greater financial insecurity
Decreased quality of life
Premature death
What is the defintion of delirium?
Sometimes called acute confusional state
- is an acute fluctuating syndrome of encephalopathy causing disturbed consciousness, attention cognition and perception
It usually develops over hours to days
Behavioural disturbance, personality changes and other psychiatric features may occur
8-17% of A&E admissions for elderly
What is the defintion of capacity?
Means the ability to use and understand the information to make a decision and communicate any decisions
Capacity assessment can be challenging
Involvement an discussion with next of kin or proxy is a key step
What must you consider to decide if a patient has capacity?
Mental disorder:
- mental illness
- learning disability
- dementia
- acquired brain injury
- severe communication difficulties due to physical disability (stroke or sensory impairment)
- of sonhas it made the person unable to make decisions
How to explain things to patients with limited capacity?
Action or decision needed
- Why the action or decision is needed
- Likely effects of decision
- Likely effects of not making decision
- Any other choices open to the person
Use broad terms and simple language
Explain the 2 strands to understanding for capacity?
There is having a grasp of the facts
The ability to weight up the options and forsee the different outcomes or possible consequences of one choice to another
What is the defintion of limited capacity?
Faced with choices, a person should be able to understand and weigh up information about options and any risks involved- and acy on the decision.
In certain cases, an adult may be able to understand the information but unable to act due to their physical or mental impairment
What is the defintion of polypharmcy?
Five or more medications
- use of multiple medications that are unnecessary and have the potential to do more harm
Describe the deprescribing process of medications?
Review mefs
Identify inappropriate, unnecessary or harmful
Plan deprescribing
Regularly review
What are the symptoms of anticholinergic burden?
Symptoms:
- brain - drowsiness dizziness, confusion and hallucinations
- heart - rapid HR
- bladder - urine retention
- skin - unable to sweat
- bowel - constipation
- mouth - dry
- eyes - blurred vision
What is the defintion of anticholinergic burden?
Several commonly prescribed medications may not be thought as anticholinergic but do have significant anticholinergic effects+ on top of actual anticholinergics will cause adverse effects.
Medications that have anticholinergic side effects?
Antihistamines
Tricyclic antidepressants
Asthma drug
COPD drugs
What other cause can cause fraility? And risk factors
Clostridium difficile
RF:
- antibiotics
- advanced age
- prolong hospital
- ppi use
- chemo
- ckd
- IBD
- low vit d
