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CSP1 YR5 > Human Disease YR4 > Flashcards

Human Disease YR4 Flashcards

1
Q

When were GAs banned in GDPs?

A

2000

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2
Q

Name the 3 categories of pateints whom should recieve a GA?

A
  • 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
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3
Q

What is the definition of anaesthesia?

A

A reversible iatrogenic state characterised by unrousable unconciousness and reflex depression

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4
Q

Unarousable Unconsciousness - IV agents and gaseous agents?

A

IV:- propofol- thiopentone- ketamineGaseous:- volatile - isoflurane/sevoflurane/desflurane- NO2

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5
Q

IV anaestehtics - aim? side effects? adverse affects?

A

UnconsicuosnessSides:- loss of airway reflexes- stop breathing- depress cardiac functionAdverse:- death

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6
Q

Volatile anaestehtics - aim? side effects?

A

UnconsicuosnessSides:- loss of airway reflexes- stop breathing- depress cardiac function

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7
Q

What is the defintion of reflex depression?

A

Drugs which cause unconsciousness depress some reflexesLarger doses of iv or volatile anaesthetic- greater reflex depression- more side effectsThe degree of reflex depression required will depend on the surgery being performedDecrease the noxious stimulus (input)Local anaesthetic nerve blockAnalgesic drugs Decrease the response to stimulus (output)Local anaesthetic nerve blockNeuromuscular junction (NMJ) blocking agents

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8
Q

Explain the process of a GA?

A

Preparation- Fasting (6 hrs food, 2 hrs fluid)- ConsentInduction -IV or inhalationMaintenance- Volatile or continuous IV infusion propofol- Reflex suppressionEmergence - Reverse NMJ blockers- Turn off anaesthetic agent

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9
Q

What is monitored during a GA?

A

Airway- Facemask +/- oropharyngeal/nasopharyngeal airway- Laryngeal mask airway- Endotracheal tube Oral, nasal or tracheostomyBreathing- Spontaneous- Intermittent Positive Pressure Ventilation- Monitoring- SpO2, gas analysisCirculation- Monitoring -HR, BP, ECG- IV access, fluids

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10
Q

The art of GA - what is included?

A

Tailoring the anaesthetic to PatientSurgeryPre-operative assessmentIntra-operative carePost-operative careCommunicationNon-technical skills

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11
Q

Why is dental GA more risky than general GAs?

A

Shared airway- Competing for same space- Airway soiling (blood/saliva)- LaryngospasmAnxious patients- Mask/needle phobiasSignificant co-morbidities- Learning disability Epilepsy/cardiac anomalies/airway/neck- Blood borne diseases

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12
Q

Solutions to a shared airway?

A

Nasal mask - patient exhales at youLaryngeal mask airway - takes up a lot of room in operative fieldNasal endotracheal tube - more technique sensitive and needs more drugs - higher risk for failureTrachestomy - highest risk - but best outcome

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13
Q

Whom should recieve conscious sedation?

A

Should be considered in preference to GA

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14
Q

What is conscious sedation?

A

Patient remains conscious and is able to both understand and respond to verbal commands either alone or accompanied by a light tactile stimulusVery 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 risksUsually in combination with local anaesthesia

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15
Q

Drugs for conscious sedation? - Benzos, IVs and gaseous?

A

Benzodiazepines- Oral temazepam/diazepam- IV midazolam- TransmucosalIntravenous anaesthetic agents- PropofolIntravenous opiods- FentanylGaseous- Volatile anaesthetics Isoflurane/sevoflurane/desflurane- Nitrous oxide in oxygen

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16
Q

Antidotes for conscious sedation drugs - Benzos, Opiates? Propofol and NO?

A

Benzodiazepines- FlumazenilOpiates- NaloxonePropofol, ketamine- No antidoteNitrous oxide, volatile anaesthetics- No antidote

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17
Q

Describe the process of conscious sedation?

A

Consent for treatment- Children, Mental Capacity ActEnvironment/equipment- Pulse oximetry, BP Team/ training- Basic Life Support, critical incidentsRecovery, discharge, aftercareClinical governance/ audit/ incident reporting

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18
Q

Name the risks of conscious sedation

A

OversedationLoss of airwayRespiratory depressionVomiting and aspiration Idiosyncratic reactionsDelayed recovery

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19
Q

Describe the basic technqiues and process for conscious sedation?

A

IV midazolamInhalational with nitrous oxide/oxygenOral / transmucosal benzodiazepineOnly nitrous/oxygen is considered basic in children under 12Require training- Must have competence in IV techniques to perform ANY basic techniqueMonitoring- BP, pulse oximetryOperator sedationist with dental nurse assistant

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20
Q

Describe the advanced technqiues and process for conscious sedation?

A

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, ketaminePropofol either alone or with any other agent for example: benzodiazepine, opioid, ketamineInhalational sedation using any agent other than nitrous oxide / oxygen aloneCombined (non-sequential) routes for example: intravenous + inhalational agent (except for the use of nitrous oxide / oxygen during cannulation)Require a lot more trainingRescue- Airway competencies (basic airway manoeuvres, airway adjuncts and the ability to administer positive pressure ventilation) are mandatory Monitoring- BP, pulse oximetry, capnographySeparate sedationistTeam 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

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21
Q

What was included in the Poswillo Report 1990?

A

Avoid general anaesthesia where possibleSame standards of monitoring, personnel and equipment should apply whether anaesthetic is delivered in hospital or dental surgeryStandards of resuscitation training setDental surgeries should be inspected and registered

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22
Q

Role of the general dental practitioner when suggesting anaesthesia?

A

Need to be aware of- Risks of GA- Alternatives to GA- Process of care for GAPatient selectionPatient preparationConsent

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23
Q

ASA classification of a patient?

A

I Normal healthy patientII Patient with mild systemic diseaseIII Patient with severe systemic disease that limits activityIV Patient with severe incapacitating systemic disease (constant threat to life)V Moribund patient with poor survival prognosis (< 24 hours)

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24
Q

Risk of death due to GA, in accordance to ASA classifcation of patient?

A

ASA 1 - 0.4 per 100,000ASA 2 - 5 per 100,000ASA 3 - 27 per 100,000ASA 4 - 55 per 100,000

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25
Q

Name the 5 categories for death under GA and their examples?

A

Airway- Failed intubationAnaphylaxis- Neuromuscular blocking agents/Latex/AntibioticsUnderlying disease process- Known/unknown - Cardiac, respiratory, vascular, neurological, malignant hyperpyrexiaComplications- AspirationIatrogenic- Injury/error/equipment failure

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26
Q

What conditions give severe morbidity due to GA?

A

Cervical spinal cord injury- Very elderly, atlanto-axial subluxation Hypoxic brain injury- Airway, breathing, BPMIStrokeEverything that can cause death

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27
Q

How can the dentist minimise risk for the patient for a GA?

A

History - Medical, drug, allergy, previous anaesthetics, family, socialExamination- Particularly airway, respiratory, cardiovascularInvestigationMost of this can be done by GP or anaesthetic pre-assessment clinic if the dental practitioner recognises the risks at the time of referralIdentification of risk factors before referralIs 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?

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28
Q

Name 6 airway conditions that may contraindicate GA?

A

Obesity/sleep apnoeaCurrent head/neck pathologyPrevious surgery/radiotherapy/burnsTMJ dysfunctionNasal obstructionGastro-oesophageal reflux

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29
Q

What to include for an airway examination before GA procedure?

A

Thyromental distance- <6cmNeck movementJaw subluxationMalampatti scoreInter-incisor distance- <3cm Teeth- Over-bite, crowded mouth

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30
Q

Name and 3 classess of jaw subluxation?

A

Class AClass BClass C

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31
Q

Describe class A jaw subluxation?

A

lower inciosrs can be protruded anterior to the upper incisors

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32
Q

Describe class B jaw subluxation?

A

lower inciosrs can be brought edge to edge with the upper incisors

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33
Q

Describe class C jaw subluxation?

A

lower inciosrs can’t be brought edge to edge with the upper incisors

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34
Q

Name the 4 mallampatti scores?

A

I - soft palate, uvula and pillars visibleII - soft palate and base of uvula visibleIII - only soft palate visibleIV - only hard palate visible

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35
Q

Which patients need and don’t need a GA?

A

For some ASA 1 anxious patients GA is the obvious choiceFor some with severe co-morbidity, GA will be too riskyFor some GA is necessary, but level of risk may require change in treatment planDental clearance instead of restorative treatmentDiscuss if unsure

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36
Q

What occurs for adult pre-assessment on day of GA?

A

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 clinicRecommend day-case or in-patient care

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37
Q

Expected schedule for a day-case GA?

A

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 fluidsNurses complete admission paperworkDentist and anaesthetist will review before list startsMay be up to 12 patients/day - Someone has to be last on list!Occasionally patients are cancelled on day of surgery

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38
Q

What is the day case discharge criteria?

A

Normally nurse-ledMust wait a few hours post-opEat/drink/pass urinePain, nausea & vomiting controlledLive within 1 hour of hospitalResponsible person to accompany them home & stay overnightFailure may result in overnight stay

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39
Q

What occurs for in-patient GA?

A

Surgical, medical or social reasonsPost +/- pre-op overnight stayMultiple days off work/education

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40
Q

What occurs for paediatric GA?

A

Mainly day-case- Inpatient care very rare for paeds dental casesParent/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 admissionFasting - 6hrs food/4hrs breast milk/2 hours fluidsIf pre-med required, at least half day

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41
Q

What occurs for special needs GA?

A

Paeds or adultVery variable processOften complex medical risksBalanced against holistic concernsCan be extremely challenging to strike right balanceMeticulous assessment and planning requiredCombining multiple procedures under GA - Better for patient - Very difficult to arrange

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42
Q

How is a patient prepared before a GA?

A

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

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43
Q

How is consent achieved for GA?

A

Process should start with general dental practitionerRequires capacity and competence - Adults with incapacityAdult/special needs/childCompetence - Scottish and English Law differ

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44
Q

What is the defintiion of the Bolam test?

A

doctor’s conduct would be supported by a responsible body of medical opinion, no longer applies to the issue of consent.

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45
Q

The 3 questions to think about when assessing whther the patient can consent effectively?

A

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?

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46
Q

What questions should you ask for history of a swelling?

A

Onset, course durationPainful or painlessOther lumpsEffect on general conditionCauseDoes the lump disappear

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47
Q

What types of onset describe swelling?

A

Gradual - benignRapid - inflamatoryAcute - bleeding into cystAccidental - ?Incidental - during clinical exam

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48
Q

History of swelling - duration?

A

Malignancy is unlikely with long timeRecent changes to the lump, can show malignancyHow long?

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49
Q

History of swelling - painless or painful?

A

Painless- most lumpsPainful- traumatic- malignant but only late (indicate infiltration if local nevres and surrounding structures

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50
Q

History of swelling - other lumps?

A

Other lumps anywhere else?

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51
Q

History of lump - effect on general condition (different types of lumps)

A

Benign/early malignant lump- no effectInflammatory lumps- symptomaticMalignant lumps- weight loss and

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52
Q

History is swelling - cause?

A

TraumaPrevious surgery

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53
Q

History is swelling - does the lump disappear?

A

If it disappears, its a hernia

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54
Q

How to exam a swelling?

A

A general exam:- overall person condition Local exam:- inspection - palpation- percussion - auscultation

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55
Q

How to describe the inspection of a swelling?

A

Site - specific (near structures) SizeShapeSurface (smooth or irregular Skin overlying (normal, inflamed, scars or dilated veins)

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56
Q

Dilated veins? Main differential diagnosis

A

Degree of venous obstruction

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57
Q

Special signs that indicate to a specific diagnosis?

A

Movement with swallowing:- seen in thyroid swellingsMovement with protrusion of the tongue:- seen in thyroglossal cystPulsations:- seen in swellings related to arteries- aneurysm (dilated artery)Cough impulse:- seen in hernia

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58
Q

How many Ss for swelling inspection?

A

6SiteSizeShapeSurfaceSkin overlyingSpecial signs

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59
Q

Palpation - what are key to conducting a palpation?

A

Firstly, ask if anything is painful and if anything becomes painful tell meComparison of temperature of skin and the swelling (= increased vascularisation or inflammation)SizeSurface: smooth or irrevularEdge: Well defined or ill defined (cancer)Consistency: cystic or soldRelation to surrounding structures:- skin- muscles - arteries and othersDraining lymph nodes* - enlarged lymph nodes (= metastasis or inflammatory)Special signs

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60
Q

Palpation - consistency - what to look for?

A

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)

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61
Q

Palpation - relation to surrounding structures - skin?

A

Is the lump separate from overlying skin?- pinch skin over lumpLump tethered to the skin?- lump can move with rangeLump fixed to the skin?- lump and skin move together (= cancerous)

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62
Q

Palpation - relation to surrounding structures - muscles?

A

Superficial to the muscle- more prominent on contractionDeep to the muscle- not felt on contractionInside the muscle- less prominent and fixed when contracting SCM - push against face to opposing sides

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63
Q

Special signs - transillumination?

A

Shine a light through a swelling - must be clear liquid and so also must be cystic Lymphatic hygroma

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64
Q

What is auscultation?

A

Listening over the swelling to decide whether cystic

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65
Q

What is a stoma?

A

An artificial opening made into the surface of the body leading to the gut

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66
Q

Name the 2 types of stoma?

A

Ileostomy - small bowel (4/5 changes) above the skinColostomy - small intestine (1change) flush with the skin

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67
Q

What isnthe function of the nasogastric tube?

A

To prevent vomiting and aspiration Allows decompression of stomach and small bowelLarge pore tube

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68
Q

How to achieve nutritional support for a patient

A

Enteral feeding tube - fine pore NG tube

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69
Q

How to achieve nutritional support for a patient without access to the oesophagus?

A

PEG tube- percutaneous endoscopic gastrostomy

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70
Q

How to achieve nutritional support for a patient with no stomach?

A

Jejumostomy tube

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71
Q

How to achieve nutritional support for a patient that can be fed eneterally?

A

Parenteral feeding - total parenteral nutrition

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72
Q

Name generic urinary catheter?

A

Foley’s catheter

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73
Q

Drains?

A

BloodBileFluid

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74
Q

Chest drain? Why?

A

Remove blood from chest

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75
Q

Name the 6 sub-specialities of surgery?

A

NeuroCardiothoracicUrologyOrthoPlasticsMaxillofacial

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76
Q

Name the 4 sub-categories of a general surgery?

A

Upper GI - oesophagastricLower GI - colorectalHBP - hepatic, biliary and pancreaticBreast - breast

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77
Q

Somatic pain vs visceral pain?

A

Somatic:- sharp- more severe- localised Visceral:- vague- not localised - less severe

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78
Q

Rationale of minimally invasive surgery?

A

Smaller access sizeNo compromise on surgical successReduction of trauma of access

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79
Q

How to improve surgical vision?

A

CO2 pumped into abdomen to increase SA and allow better visual

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80
Q

Benefits (5) of minimally invasive surgery?

A

Less scarringLess painFaster recoveryShorter hospital stayQuicker return to normal activity

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81
Q

Limitations of the laproscopic camera?

A

Camera controlled by assistant2D image for 3D ideaLimited retractionLimited dexterityLimited to do higher precision tasks

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82
Q

Advantages of robotics?

A

Camera controlled by surgeon Better magnificationMore movement3D

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83
Q

Cardiovascular risk for patient with pregnancy?

A

Increased pulse but lower BPIncrease of 40% of plasma volumePossible fainting and palpitations

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84
Q

Gastrointestinal risk for a pregnant patient?

A

Decreased oesophageal pressureDecreased gastric emptyingDecreased gastrointestinal motilityNausea and vomitingHeartburnConstipation

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85
Q

Musculoskeletal risk for the pregnant patient?

A

Change in posture - sciatica painRelaxation of pelvic jointsBack painPelvic girdle pain

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86
Q

Respiratory risk for pregnant patient?

A

Decreased total lung capacity, but tidal volume increasesSoBProblem with GA as less time for intubation - swollen larynx and pharynx

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87
Q

Urinary risk for a pregnant patient?

A

Right sided hydronephrosis, with increased urinary stasisIncreased urinary frequencyUTI increases preterm births

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88
Q

Haemoglobin risk for pregnant patient?

A

Thrombophillic state, a fall in haemoglobinIncreased risk of DVT/PE and anaemia

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89
Q

Useful medications to aid with haem for pregnant patients?

A

Aspirin to reduce risk of pre eclampsia and improves placental functionDoltaparin - blood thinner

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90
Q

Drugs for nausea and vomiting?

A

Anti-emetics - cyclazine

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91
Q

Drugs for stomach?

A

Omeprazole

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92
Q

Name the common dental conditions in pregnancy?

A

Pregnancy gingivitis- increased inflammation - increased bleeding- worst in 3rd trimesterBenign oral growth lesions- 5% of pregnanciesTooth erosion/dental caries- increased acidity in the mouth- secondary to vomitingIncreased tooth mobility

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93
Q

Name the 3 clinical considerations for pregnancy and dental procedures?

A

Inferior vena cava compressionAirway oedemaBreast enlargement Ensure patient lies on the left side to avoid vessel compression (pack a pillow down the side)

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94
Q

Drug for heartburn?

A

Ondansetron

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95
Q

If patient has collapsed, and patient is in late term pregnancy, what should you do?

A

DeliverResuscitation is impossible as bump is very large

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96
Q

Periods of fatal development?

A

CNS - 3 weeks to full termEars - 4 1/2 to 20Teeth - 6 3/4 to full termPalate - 6 3/4 to 16Upper limbs - 4 1/2 to 9External genitalia - 7 to full termLower limbs - 4 1/2 to 9 Heart - 3 1/2 to 9Eyes - 4 1/2 to full term

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97
Q

Valproate - never in pregnancy? Why?

A

Valproate- epilepsy- folate antagonist- assoc with neural tube defect- ideally avoid in women of child bearing age or change to another drug pre pregnancySpina bifida

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98
Q

Tetracyclines - never in pregnancy? Why?

A

Tooth stainingSkeletal developmental problems

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99
Q

Warfarin - never in pregnancy? Why?

A

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

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100
Q

Alcohol - never in pregnancy? Why?

A

No safe level of alcoholFetal alcohol syndrome - developmental delay, behaviour issues, characteristic facial features (thin upper lip, smooth philtrum and decreased eye width)

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101
Q

Name 4 teratogens?

A

ValproateTetracyclinesWarfarinAlcohol

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102
Q

Is paracetamol safe during pregnancy?

A

YES

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103
Q

Local anaesthetic in pregnancy?

A

Lidocaine with adrenaline is not harmful to baby, if in normal dosesCan cause neonatal respiratory depression, hypotonia and bradycardia in large dosesAdrenaline can cause reduction in placental perfusion

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104
Q

Antibiotics in pregnancy?

A

Penicillin, amoxicillin and metronidazole all safeAvoid:- tetracycline - skeletal effects (1st) and tooth discolouration (2nd and 3rd)- gentamicin (unless patient is very unwell)- ciprofloxacin (arthropathy)

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105
Q

Painkillers during pregnancy?

A

Paracetamol safeNSAIDs - avoided in 3rd trimester as can cause ductus arteriosusDihydrocodiene - small risk of neonatal respiratory depression

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106
Q

Common drugs to consider for pregnancy? That are very good for pregnancy

A

Aspirin - reduces the risk of a small baby and hypertensive disordersHeparin - reduces the risk of DVT/PE

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107
Q

X-ray risk for pregnant patient?

A

Commonest teratogenic effect of radiation:- microcephalic with several mental regards option- main effect between 10-17 weeks- very little risks before 10 and after 27Threshold dose:- >250 mGy 0.1% risk- >1000 mGy microencephaly, growth restriction, genital and skeletal malformation

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108
Q

Does dental health affect pregnancy?

A

More linked to socioeconomic status - and that’s why poor dental hygiene was linked

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109
Q

Name the 7 principles of palliative care?

A

Focus on QoLWhole person holistic approach good symptom control Care of patient and family as a unitRespect for patient autonomyEmphasis on sensitive/open communicationAffirms life and regards digs as normal

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110
Q

Name the 4 categories of palliative care?

A

PhysicalPsychologicalSpiritualSocial

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111
Q

What tool to use to score a patients deterioration?

A

Supportive and Palliatice care indicators tool (SPICT)

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112
Q

Common symptoms for palliative patients?

A

PainNauseaVomitingRespiratory secretionsSoBAnxietyAgitationConstipationFatigueAnorexiaOral thrush

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113
Q

What medications can be prescribed for palliative care?

A

Opoids - morphineAnxiolytics - midazolamAntiemetic - levomepromazineAntisecretory - hyoscine butylbromide

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114
Q

What is included for end of life care?

A

Individualised ComfortSymptom control CommunicationHydrationAnticipatory messPsychosocial support for patient and relative

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115
Q

When should specialist palliative care be advised?

A

Complex symptoms controlEnd of life careRehabilitation

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116
Q

How to aid planning for palliative care?

A

Palliative and supportive care plan 2017Place of care and deathTreatment they don’t want

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117
Q

What is the definition of palliative care?

A

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

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118
Q

What is the defintion of dental palliative care?

A

Holistic approachRelief from painTeam approachPalliative care alongside treatments

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119
Q

5 factors for oral health in palliative care?

A

QoLCommunicationFacial appearanceDrinkingEating

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120
Q

Optimum oral health characteristics?

A

Normal and intact immunityNormal saliva productionIntact mucosa

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121
Q

Aetiology of painful mouth?

A

Generalised:- candidiasis - mucositisLocalised:- tumour- aphthous ulcers- herpes simplex or zoster- dental

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122
Q

General advice for all patients for dry mouth?

A

Mouth and lips clean most and intact from plaqueMaintain fluid intakeWater based gel to dry lipsReduce sugary foods and drinks

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123
Q

Name 11 causes for devteased saliva production?

A

Rheumatoid conditionsPrimary biliary cirrhosisPancreatic insufficiencyHIV/AIDSCystic FibrosisStrokeAnxiety/DepressionAgeingChemotherapyRadiotherapyDrugs

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124
Q

Describe the Challacombe Scale for oral dryness?

A

Scale of 1-10 of how severe the oral dryness is1-3 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.

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125
Q

Challacombe scale grade 1?

A

Mirror sticks to mucosa

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126
Q

Challacombe scale grade 2?

A

Mirror sticks to tongue

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127
Q

Challacombe scale grade 3?

A

Frothy saliva

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128
Q

Challacombe scale grade 4?

A

No saliva pooling in floor of mouth

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129
Q

Challacombe scale grade 5?

A

Tongue shows generalised shortened papillae

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130
Q

Challacombe scale grade 6?

A

Altered gingival architecture (smooth)

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131
Q

Challacombe scale grade 7?

A

Glassy appearance of oral mucosa, especially palate

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132
Q

Challacombe scale grade 8?

A

Tongue lobulated or fissured

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133
Q

Challacombe scale grade 9?

A

Cervical caries in more than 2 teeth

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134
Q

Challacombe scale grade 10?

A

Debris on palate or sticking to teeth

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135
Q

Name the 8 effects of xerostomia?

A

Dental cariesGingivitisHalitosisAltered tasteCandiadisisMouth ulcersFissuring of tongueChewonf difficulties

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136
Q

Describe saliva composition?

A

99% water1% - mucin, electrolytes, enzymes and proteins

137
Q

Name the 7 functions of water in saliva?

A

LubricationCleansingTasteSpeechFood prepMucosal protection

138
Q

Name the 3 functions of mucin in saliva?

A

LubricationMucosal protectionFood prep

139
Q

Name the functions of enzymes in saliva?

A

Digestion

140
Q

Name the functions of proteins in saliva?

A

Antimicrobial

141
Q

Name the 2 functions of electrolytes in saliva?

A

Buffering Mucosal protection

142
Q

Describe the 9 options for dry mouth management

A

Treat underlying causeReview medsGood OHDietary adviceRegular check upsRegular sips of waterLubricate lipsSaliva substitutes Saliva stimulants

143
Q

Name 4 saliva stimulants?

A

PilocarpineChewing gum - sugar freeOrganic acids - salivix pastillesAcupuncture?

144
Q

Name 5 saliva substitutes?

A

WaterGlandosaneSaliva orthana lozenges or spray Biotene oralbalance saliva replacement gelBioXtra gel

145
Q

Describe orthana saliva spray?

A

Mucon-containing saliva substitutes porcine derivative

146
Q

Describe glandosane?

A

Low pH can damage teeth

147
Q

What is the defintion of oral mucositis?

A

Affects people who are recieving radio or chemoAffects 85-100% of H and N patients 2 in 3 patients with mucositis will need a lowered dose or hospitalisation

148
Q

How to manage mucositis?

A

Analgesia Mouth rinseMucosal protectantSystemic therapies

149
Q

What analgesia can be used for mucositis?

A

Increases protectionDecrease inflammation - benzydamine mouthwash - benzydamine oromucosal spray Analgesia- topical- systemic

150
Q

How to use chlorhexidine gluconate 0.2% mouthwash

A

Can be diluted 1:1 with water

151
Q

Name other types of mouthwash for mucositis?

A

Tea tree mouth washCaphasol mouth rinse

152
Q

How to use gelclair mucosal protectant?

A

Forms a protective coatingA gel for lesion oropharyngeal cavity Provides pain relief

153
Q

Name a systemic therapy for mucositis?

A

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

154
Q

Name 6 causes of painful mouth?

A

Trauma - sharp teethHaematinic deficiency Viral infection (herpes simplex)Aphthpus ulcerationOral malignancy Mucositis

155
Q

What other treatments for mucositis?

A

Milder toothpastesHigh dose fluoride

156
Q

What other side effects of radiotherapy?

A

MucositisOral ulcerationRadiation caries

157
Q

Oral infection risk for cancer patients?

A

FungalViralBacterial

158
Q

Side effects of cancer treatment, oral relation?

A

Taste disturbanceXerostomiaMRONJ

159
Q

What is the definition of multimorbidity?

A

coexistence of two or more chronic conditions

160
Q

How does multimorbidity affect care?

A

major impact on quality of life, increased risk of mortality, and places significant financial costs to the health and social care system

161
Q

Common multimorbiditiy diseases?

A

diabetes, multiple drug interactions, cardiac abnormalities, and infectious disease.

162
Q

What is the role of Special Care Dentistry?

A

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

163
Q

What is the acronym RSVP?

A

Recency - recent events (hospital) acute medical episodesSystemic symptoms - pain or breathlessnessVital signs - C, BP, RR, HRPrescription drugs - Interactions

164
Q

How to determine the patient’s quality of life?

A

Quality of Life- living with chronic pain / disability : depression- dependant on medication + carersWhat are they looking for?- oral health not high priority: pain relief, appearance (Serban 2019) - communication and trust (Cumella 2000)

165
Q

What systems to group meds into?

A

CardiacRespiratoryCNSEndocrineEverything else

166
Q

What to think about when looking at patient’s meds list?

A

Recognise conditions + severityAdverse medical eventsBleeding + healing issuesLA / IVS issuesDental prescribing : interactionsPrevention: xerostomiaRed flags

167
Q

A general rule of thumb for patient’s medication?

A

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.

168
Q

Describe the increasing severity of HBP, with medications?

A

bendroflumethiazide - MildBendro with Ramipril - ModBendro with Ramipril with amlodipine - severe

169
Q

Cardiac patient’s main causes for referral to SCD?

A

unstable anginapre cardiac surgery

170
Q

At what ASA level must a patient ne referred to a hospital setting?

A

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

171
Q

Name immunosuppressed patient 2 medications and 4 side effects?

A

CancerChemoRadioMethotrexateThese patient’s need screening of their conditions to allow them to receive the best treatmentSteroids - Prednisolone , Dexamethasone Side effects - Osteoporosis, Diabetes, Hypertension- Mood changes, weight gain, gastric ulceration, adrenal suppression

172
Q

Name 4 common meds for a transplant patient?

A

SteroidsAzothioprineCiclosporinTactolimus

173
Q

Name 7 other commonly referred patients to SCD?

A

Respiratory DiseaseLiver DiseaseRenal diseaseDiabetesEpilepsyCongenital Bleeding DisordersRheumatoid Arthritis

174
Q

What is the definiton of a hypersensitivity reaction?

A

A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign agent

175
Q

What is the defintion of an allergy?

A

response by the immune system to an otherwise innocuous antigen

176
Q

What is the summary for type I hypersensitivity?

A

Immediate hypersensitivity IgE mediatedAnaphylaxis - Urtcaria

177
Q

What is the summary for type II hypersensitivity

A

Cytotoxic hypersensitivityIgG or IgM mediatedDrug induced thrombocytopenia

178
Q

What is the summary for type III hypersensitivity

A

Immune complex mediated hypersensitivity Antigen-antibody immune complex Serum sickness Vasculitis

179
Q

What is the summary for type IV hypersensitivity

A

Delayed hypersensitivityT cell mediatedContact dermatitis

180
Q

Name the 5 symptoms of TI hypersensitivity?

A

UrticariaAngioedemaBronchoconstrictionAllergic rhinitis/conjunctivitisAnaphylaxis

181
Q

Explain Latex allergy MoA?

A

TI or TIVIf type 1 allergy- Most problems from skin or mucous membrane contact with latexBanana, kiwi, chestnut, avocado, pineapple, passion fruit, apricot, and grape

182
Q

What allergen test to do for a TI and TIV reaction?

A

Type 1 allergy- Serum specific IgE levels- High rate of false positive results if atopic- Skin prick tests- Challenge testingType 4 allergy- Patch testing

183
Q

Name the 16 dental allergens?

A

5 Acrylates5 metal salt compounds (mercury, golds, palladium,platinum)2 resin chemicalsFlavouring (eugenol, peppermint)Activators/curing agents(Benzoyl peroxide, hydroquinone)

184
Q

Name some other rare allergens in dentistry?

A

Preservatives (formaldehyde, sodium metabisuphite, methylisothiazolinone)SteroidsRubber accelerators Local anaesthetic reactions (type 1 or 4)

185
Q

What is the defintion if a macule?

A

Non-palpable change in skin color with distinct borders

186
Q

What is the defintion of a patch?

A

Non-palpable change in skin color with distinct borders

187
Q

What is a papule?

A

Palpable, solid lesion less than 1 cm in diameter

188
Q

What is a plaque (skin)?

A

Palpable, solid lesion greater than 1 cm in diameter

189
Q

What is a nodule?

A

Palpable, lesion more than 1 cm in diameter which is taller than it is wide

190
Q

What is a vesicle?

A

Fluid-containing, superficial, thin-walled cavity less than 1 cm

191
Q

What is a bulla?

A

Fluid-containing ,superficial, thin-walled cavity greater than 1 cm

192
Q

What is erosion?

A

skin defect where there has been loss of the epidermis only

193
Q

What is an ulcer?

A

A skin defect where there has been loss of the epidermis and dermis

194
Q

What is a pustule?

A

Pus containing, superficial, thin-walled cavity

195
Q

What is an abscess?

A

Thick-walled cavity containing pus

196
Q

What is paraneoplastic pemphigus associated with (cancer)?

A

NHLCLLDiscriminatory sign is intractable stomatitis

197
Q

What is the defintion of bullous pemiphigoid?

A

Again common in the elderlyWidespread pruritic eruptionTense bullae seen

198
Q

How to diagnose, test and treag for immunobullous disease?

A

Consider diagnosis in non-resolving stomatitis in Elderly patientsDiagnosis is made by biopsy of mucosa or skin adjacent to the ulcer/erosionSent for direct immunofluorescence (DIF)Treatment is immunosuppressionhigh dose oral corticosteroids

199
Q

What is the deifntion of skin related erythema multiforme?

A

Acute self–limiting, but may be recurrentAbrupt onset of target lesions ~ 24hrsFavours acrofacial sitesEM minor – target lesions with little/no mucosal involvementEM major – target lesions with severe mucosal involvement and systemic symptomsPredominantly young adults

200
Q

What is the aetiology for erythema multiforme?

A

Commonly associated with infection (90%)- Viral: HSV, orf, EBV, CMV, viral hepatitis, adenovirus- Bacterial: Mycoplasma, salmonella, mycobacterial- Fungal: Histoplasmosis, dermatophytesOther 10%- Drugs, systemic diseases (SLE, IBD), poison

201
Q

What is the treatment for erythema multiforme?

A

Treat precipitating causeSupportive careTopical anaesthetic and antiseptic rinsesMeticulous eye care if neededShort course oral steroid if severeIf due to HSV and recurrent episodesConsider long term antiviral treatmentIf not due to HSV and recurrentConsider dapsone or immunosuppressant

202
Q

Name the 7 forms of oral lichen planus?

A

AtrophicbullousErosivepapularpigmentedplaque likeReticular

203
Q

Name some oral lichenoid reaction materials?

A

Amalgam, composite/resin based materialsPorcelain, glass ionomer cement, Cobalt, gold, nickel, palladium, titaniumCinnamon, eugenol, menthol, peppermint, vanilin

204
Q

What is the defintion of orofacial granulomatosis?

A

Persistent, non-tender swelling of the lip and or faceNon-caseating granulomatous inflammationUsually only upper or lower lip is affectedSome think it is a food or additive hypersensitivity reactionMay be a sign of underlying crohns disease or sarcoidosis

205
Q

What is the defintion/aetiology of angular cheilitis?

A

Drooling (age related, neurological issue)Irritant contact dermatitisDry lips/environmentalDeep Marionette linesInfection (bacterial, fungal, viral)MedicationPoor nutrition

206
Q

What is the definition of perioral dermatitis?

A

Tender or itchy papules around the mouthUnaffected zone around lipsRebounds after topical steroidsCan also get periorbital dermatitisTreat by stopping everythingTopical or oral antibiotic may be neededIf severe topical tacrolimus or oral retinoid

207
Q

Name 6 benign skin lesions?

A

Seborrhoeic keratosesViral wartsCystsDermatofibromaLipomaVascular lesions

208
Q

Name 3 premalignant skin lesions?

A

Bowens diseaseActinic KeratosesMelanoma in situ

209
Q

What is the defintion of a seborrheoic keratoses?

A

Benign, but commonly referredWarty growths, “stuck on appearance”Patients often have multiple +/- cherry angiomasGenerally left untreated, but if troublesome- Cryotherapy- Curettage

210
Q

Pros and cons of cryotherapy?

A

Liquid nitrogenPros CheapEasy to perform “on the day”ConsCan scarFailure/RecurrenceNo pathology result

211
Q

What is the definition of Leser-Trelat?

A

Paraneoplastic phenomenonAbrupt onset of widespread seborrhoeic keratosis, particularly in a younger individualPremaliganncy for GI adenocarcinoma

212
Q

What is the defintion of a viral wart?

A

Due to Human Papilloma VirusRough hyperkeratotic Will clear when immunity developed to virusCryotherapy or wart paints can stimulate immune system slightlyCan curette in severe cases

213
Q

What is the defintion of a cyst?

A

Encapsulated lesion containing fluid or semi-fluid materialUsually firm and fluctuantMultiple different types of cyst exist

214
Q

What ks the treatment for cysts?

A

Can rupture and cause inflammation of surround skinMay become secondary infectedTreated with excisionIf inflammed/infectedAntibioticsIntralesional steroid

215
Q

What is the defintion of dermatofibroma?

A

Benign fibrous nodule, often on limbsProliferation of fibroblastsCause 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 positiveUsually asymptomatic. Can be itchy or tenderExcision if concern or symptomatic.

216
Q

What is the defintion of a fibroma?

A

Benign tumour consisting of fat cellsCommonCause unknownSmooth and rubbery subcutaneous massUsually asymptomaticIf tender?angiolipoma?Liposarcoma – rare malignancy

217
Q

Name 2 vascular lesions?

A

AngiomaPyogenic granuloma

218
Q

What is the definfion of an angioma?

A

Overgrowth of blood vessels in the skin due to proliferating endothelial cellsGenerally asymptomatic. Can be unsightly or bleedPregnancy & liver diseaseExcision or laser

219
Q

What is the defintion of a pyogenic granuloma?

A

Rapidly enlarging red/raw growth, often at a site of trauma.Bleed easilyCause is unknownOccur in up to 5% of pregnanciesCommon on head and handsRemoved by curettage & cautery

220
Q

What is the defintion of Bowen’s disease?

A

Rapidly enlarging red/raw growth, often at a site of trauma.Bleed easilyCause is unknownOccur in up to 5% of pregnanciesCommon on head and handsRemoved by curettage & cautery

221
Q

Treat Bowen’s disease?

A

CryotherapyCurettageLesion scraped off and heat applied to seal vessels and destroy residual cancer cells

222
Q

What is the defintion of photodynamic therapy?

A

Photochemical reaction to selectively destroy cancer cellsTopical photosensitising agent appliedConcentrates in cancerous cellsRed light applied ( light colour dependant on which agent is used)Photodymanic reaction occurs between light, photosensitiser and oxygen causing inflamation and destruction of cells

223
Q

Pros and Cons of photodynamic therapy?

A

ProsDone for the patient by hospital staffCan treat multiple areas, including those which would be hard to reach by patient1 or 2 treatmentsConsRequires hospital appointmentsCan be painful and scar

224
Q

Pros and Cons of Imiquimod?

A

AldaraImmune response modifierStimulates cytokine releaseInflammation and destruction of lesionProsUseful where surgery is undesirableUsually good cosmetic resultLarge surface areaConsTreatment time is 6 weeksSignificant inflammationFailure/recurrence

225
Q

What is the defintion of melanoma in situ?

A

Melanoma cells entirely confined to epidermisNo metastatic potentialTreated with excision

226
Q

Explain how to protect self from Sun?

A

Cover upAvoid sun at peak hours 10am-4pmDon’t burn and try not to tanAvoid sunbedsSunscreenUVA & UVB protectionAt least SPF 30 / 4 StarNeed to apply 2 tablespoons every 2 hours

227
Q

Name the 7 risk factors for skin cancer?

A

UV radiationPhotochemotherapy (PUVA)Chemical carcinogensIonising radiationHuman papilloma virusFamilial cancer syndromesImmunosuppression

228
Q

What is the defintion of basal cell carcinoma?

A

Slow growingLocally invasiveRarely metastasiseNodularPearly rolled edgeTelangiectasiaCentral ulcerationArborising vessels on dermoscopy

229
Q

How to treat basal cell carcinoma?

A

Excision is gold standardEllipse, with rim of unaffected skinCurative if fully excisedWill leave a scarCurettage in some circumstancesImiquimod if superficial

230
Q

Indications for Moh’s surgery?

A

IndicationsSiteSizeSubtypePoor clinical margin definitionRecurrentPerineural or perivascular involvement

231
Q

What is the indication for vismodegib?

A

IndicationsLocally advanced BCC not suitable for surgery or radiotherapyMetastatic BCCSelectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)Can shrinks tumour and heal visible lesions in someMedian progression free survival 9.5 monthsSide Effects- Hair loss, weight loss, altered tasteMuscle spasms, nausea, fatigue

232
Q

What is the defintion of a squamous cell carcinoma?

A

Derived from keratinising squamous cellsUsually on sun exposed sitesCan metastasise, up to 16% depending on studyFaster growing, tender, scaly/crusted or fleshy growthsCan ulcerate

233
Q

What is the treatment for SCC?

A

Excision+/- RadiotherapyFollow up if high riskImmunosuppressed>20mm diameter>4mm depthEar, nose, lip, eyelidPerineural invasionPoorly differentiated

234
Q

What is the defintion of keratoacathoma

A

arient of squamous cell carcinomaErupts from hair follicles in sun damaged skinGrows rapidly, may shrink after a few months and resolveSurgical excision

235
Q

Name the 3 risk factors for melanoma?

A

UV RadiationGenetic susceptibility- fair skin, red hair, blue eyes and tendency to burn easilyFamilial melanoma and melanoma susceptibility genes

236
Q

ABCDE?

A

AsymmetryBorderColourDiameterEvolution

237
Q

7 point checklist for cancer?

A

Major featuresChange in sizeChange in shapeChange in colourMinor featuresDiameter more than 5 mmInflammationOozing or bleedingMild itch or altered sensation

238
Q

Treatment for melanoma?

A

Excision

239
Q

Can you take a radiograph for a pregnant patient?

A

YesDose 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”

240
Q

Why should you avoid Felypressin?

A

it can cause uterine contractions

241
Q

Which antibiotics are safe and dangerous for pregnant patients?

A

Yes, it is safe to prescribe penicillins Avoid: - metronidazole- erythromycin- tetracycline- doxycycline

242
Q

What pain relief to recommend to pregnant patients?

A

Paracetamol is safeAvoid:- NSAIDs- Aspirin- Dihydocodiene- Codiene

243
Q

What symptoms can a pregnant patient experience at 8 week?

A

Blood pressure drops:- fainting riskEmotional changesIncreased urinationVominitingAnaemia

244
Q

What is Dalteparin?

A

a low molecular weight heparin anticoagulantSubcut

245
Q

Is amalgam safe for pregnant patients?

A

No, it is best avoided as Mercury can crossthe placenta and has been detected in breast milkA temporary restoration should be placed insteadRemoval of an amalgam filling can carried out under rubber dam and high volume suction

246
Q

Should Duraphat be precribed for a pregnant patient? and what alternatives are there?

A

No, due o its alcohol contentNor 5,000ppm flouire toothpastes as the effects of high fluoride are unknown2,800ppm is deemed safe but must be spat out after brushingFluoirde MW of 225ppm or 900ppmFor lactating/breastfeeding

247
Q

Why to double check medical history when dealing with pregnant patients?

A

They may not know they are pregnant, or don’t feel like it is important to tell youCheck history generally

248
Q

Check for pregnancy gingivitis?

A

hormonal changes can excaerbate pre exisiting plaque induced gingivitisPossibly gestational diabetes

249
Q

Dental symptoms of first trimester?

A

increase in oestrogen and progesterone seems to coincide with increase in gingival inflammation

250
Q

Describe how hyperplasia of the gingivae looks and is caused?

A

Hyperplasia of the gingivae is caused by marked proliferation of capillaries and minimal proliferation of fibroblastsClinically it appears as dark red/purple papillae which are fragile, bleed easily. False pocketing and stagnation also may be a problem

251
Q

Describe how a pregnancy epulis occurs? and how it looks?

A

Caused by inflammatory response to local irritation which is modified by hormonal changes- 3rd month of pregMushroom 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

252
Q

How to treat a pregnancy epulis?

A

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.

253
Q

Which antifingals are safe and dangerous during pregnancy?

A

Amphotericin is safe and nystatin but Avoid:- miconazole- fluconazole(can transfer to foetus or risk malformations)

254
Q

Is there a link between periodontal disease and preterm/low birth weight babies?

A

Preterm= pre-37weeks Low birth weight < 2,500 g or 5.5lbsIncidence – over 4 million die within first 4 weeksRisk factors – young maternal age, drug alcohol and tobacco abuseMaternal stress, genetics, genito-urinary tract infectionMultiple or assisted pregnanciesResearch into interventions is not conclusivePeriodontium = reservoir of gm –ve bac, host response elevated levels of chemical mediators, premature labourNo conclusive evidence

255
Q

What is hyperemis Gravidarum?

A

continued vomitingusually during the first trimester but can be throughout. causing dehydration (dry mouth), weight loss, electrolyte imbalance and hospitalisationdon’t brush after vomiting

256
Q

How to treat a patient with erosion due to pregnancy vomiting?

A

Dress teeth, protecting the exposed enamelA dentine bonding agent ( ie Seal and Protect ) will aid protectionConsider Delaying RCT and radiographs until after birth if possibleWe should consider taking study models to observe wear, gag reflex is exaggerated due to obstruction of oesophagus

257
Q

How to deal with vena cava compression?

A

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.

258
Q

Acyclovir for cold sores?

A

Minimal absorption to the foetus, but shedding at term may lead to HSV transfer to the baby

259
Q

When is the best time for dental treatment during pregnancy?

A

Research and evidence suggests that dental care during pregnancy is safe, effective and recommended. ( best time is second trimester)

260
Q

Name the 3 main tyoes of inherited coagulation disorders?

A

Haemophilia AHaemophilia Bvon Willebrand’s disease

261
Q

Describe Haem A?

A

Factor VIIIX-linkedfemale carries can have mild bleeding tendency

262
Q

Describe Haem B

A

Factor IX defX-linked

263
Q

Describe vWD?

A

Factor VIII def and reduced platelet adhesionDominant inhertance1 in 100

264
Q

Describe symptoms of haemophilia?

A

PEOPLE WITH SEVERE HAEMOPHILIA HAVE FREQUENT BLEEDS INTO MUSCLE AND WEIGHT BEARING JOINTSMODERATE SUFFERES HAVE A FEW SPONTANEOUS BLEEDS AND IN MILD HAEMOPHILIA THE BLEEDS USUALLY OCCUR AFTER TRAUMA, SURGERY OR DENTAL EXTRACTIONS.

265
Q

Where do we treat patinets with CBD (congenital bleeding disorders)?

A
  • 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.
266
Q

What are the management strategies for CBD?

A

Some dental procedures don’t require augmentation of coagulation factor levels.Coagulation factor replacement therapyRelease of endogenous Factor stores using desmopressin (DDAVP)Improving clot stability by antifibrinolytic drugs, e.g. tranexamic acid .Local Haemostatic measuresLIASON WITH A HAEMATOLOGIST

267
Q

Wghat is the definition of DDAVP?

A

DesmopressinA SYNTHETIC HORMONE, IS A DRUG WHICH IS SOMETIMES PRESCRIBED TO STIMULATE THE RELEASE OF ENDOGENOUS FACTOR STORES.

268
Q

Describe transexamic acid?

A

MANAGEMENT STRATEGY TO IMPROVE CLOT STABILITY

269
Q

What is Haem A and B MoA?

A

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 injections15-25% people develop inhibitors or antibodies with repeated use.

270
Q

Describe the factor replacements and how they should be used?

A

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 DEVELOPMENTFACTOR IX HAS A LONGER HALF LIFE, ALLOWING DENTAL TREATMENT TO BE CARRIED OUT ON CONSECUTIVE DAYS UNDER A SINGLE DOSE OF REPLACEMENT THERAPY

271
Q

Describe vWD MoA?

A

Extended bleeding time due to poor platelet function and low levels of circulating vWF and ristocetin co-factor. 75% have mild or Type 1 vWDUsually treated with synthetic hormone desmopressin (DDAVP)Infused IV over 20 minutes at Haemophilia CentreCan also be self-administered as high strength nasal sprayMore severe types require factor replacement therapy derived from human plasma. Ristocetin co factor

272
Q

Post OP adivce for CBD?

A

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

273
Q

General principles for factor replacement?

A

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.

274
Q

Blood transfusions before 1986?

A

Non inactivated replacement factor concentrates from pooled human blood until 1986 when effective heat treatment was introduced.Risk factor of HIV and vCJD prior 199970% patients with haemophilia have presence of HCVRecombinant (non human derived) factor concentrates in early 1990’s removed the risk of viral or prion transmission

275
Q

Name the general measure to reduce bl;eding risk?

A

Minimal traumaLA with vasoconstrictorhaemostatic agents in socketsSutures (resorbable)Post OP adviceAvoid NSAIDs

276
Q

How to manage a patient needing emergency treatment with CBD?

A

Acute pulpitis - pain can usually be controlled by removing pulp from tooth. Temporary dressing until planned extractionDental abscess with facial swelling. Antibiotics only if local spread or systemic infection. Seek advice from haemophilia centreFractured teeth - normal management +/- cover if significant bleeding soft tissues

277
Q

Drugss to avoid with CBD?

A

AspirinNSAIDs

278
Q

CBD considerations for soft tissues?

A

chlorhex MWparaffin wax to avoid adherence to mucosa

279
Q

CBD considerations for resto?

A

nil

280
Q

CBD considerations for subging resto?

A

haemostatic agents - retration cord or transexamic acid

281
Q

CBD considerations for endo?

A

sodium hypochlorite irrigation and CaOH paste for bleeding control

282
Q

CBD considerations for rubber dam?

A

avoid trauma

283
Q

CBD considerations for high speed aspiration

A

avoid trauma

284
Q

CBD considerations for denture?

A

care with fittingsoft lining (if needed)

285
Q

CBD considerations for ortho?

A

prevention and oral hygiene advicewax to stop trauma

286
Q

CBD considerations for routine scaling?

A

Transexamic acid MW

287
Q

CBD considerations for perio surgery?

A

good oral hygienefactor cover

288
Q

Mild causes of red eyeness?

A

Conjunctivitis• Subconjunctivalhaemorrhage• Dry eyes• Episcleritis

289
Q

Moderate acuses of red eyeness?

A

• Corneal abrasion• Corneal foreign body• Iritis (uveitis)• Scleritis• Facial nerve palsy

290
Q

Severe causes of red eyeness?

A

• Corneal ulcer(keratitis)• Penetrating injury• Chemical injury• Acute glaucoma• Orbital cellulitis

291
Q

Questions to ask when assessing a red eye?

A

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 sensationPhotophobia – pain in presence oflight (think cornea!) Has vision been affected? Appearance of the pupilRound?Reactive to light compared to theother side?

292
Q

Which eye conditions cause pain?

A

• Corneal ulcer(keratitis)• Penetrating injury• Chemical injury• Acute glaucoma• Orbital cellulitis• Corneal abrasion• Corneal foreignbody• Iritis (uveitis)• Scleritis

293
Q

Which eye conditions affect vision?

A

Conjunctivitis• Dry eyesCorneal abrasionIritis (uveitis)Facial nerve palsyCorneal ulcer(keratitis)• Penetrating injury• Chemical injury• Acute glaucoma• Orbital cellulitis

294
Q

Which eye conditions chnage the apperance of the pupils?

A

Iritis (uveitis)Penetrating injuryAcute glaucoma• Orbital cellulitis

295
Q

Describe causes of facial nerve palsy?

A

Inferior alveolar nerve block• Parotidectomy

296
Q

How to manage facial nerve palsy?

A

Tape eye closed• Generous lubrication• Optometrist• Safety net advice

297
Q

Describe causes of corneal ulcer?

A

contact lensesvery light sensitiveurgent <24 hrsforeign bodies - high speed mechanisms

298
Q

Describe causes of subconjunctival haemorrhage?

A

asymptomaticonly cancer in traumarelated to HT and anticogulants

299
Q

Name the 2 forms of conjunctivtis?

A

bacterialViral

300
Q

Describe bacterial conjunctivitis?

A

Sticky, purulent discharge• Bilateral, sequential• Gritty, uncomfortable

301
Q

Describe viral conjunctivitis?

A

Watery, “streaming”• Bilateral• Pre-auricular lymphadenopathy

302
Q

Describe a good history taking for vision loss?

A

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?

303
Q

Name possible causes of vision loss?

A

Cataract ARMD Glaucoma Retinal detachment Giant cell arteritis

304
Q

Describe symptoms of cataract?

A

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!

305
Q

Describesymptoms of age related macular degeneration?

A

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

306
Q

Name the 3 types of glaucoma?

A

GradualChronicAcute

307
Q

Describe symptoms of gradual glaucoma?

A

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

308
Q

Describe symptoms of chronic glaucoma?

A

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

309
Q

Describe symptoms of acute glaucoma?

A

Acute closed angle glaucoma Red, painful eye, unreactive pupil, severe headache, unwell patient

310
Q

Describe the symptoms of retinal detachment?

A

Flashing light or floatersshadow in croner of visionpainlessneeds urgent surgery < 2 daysno inhalation sedation - causes acute eye pressure rises and permanent sight loss

311
Q

Describe the symptoms of giant cell arteritis?

A

Vasculitis, especially branches of externalcarotid 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

312
Q

Name eye related diseases linked with diabetes?

A

 Retinopathy - vitreous haemorrhage - retinal detachment Maculopathy- retinal oedema

313
Q

Describe the symptoms of diabetic retinopathy?

A

Sugary blood damages vessels Haemorrhages Oedema (especially at macula!) Retinal ischaemia New vessels grow into vitreous (proliferativeretinopathy) Vitreous haemorrhage Retinal detachments

314
Q

Describe the symptoms of orbital fracture?

A

Bruising Periorbital oedema Pain Double vision up- and downgaze Subconj. Haemorrhage Infraorbital anaesthesia ”Sunken” eye

315
Q

Why are orbital fractures in children more pertinent to address?

A

Entrapment more common “Bend and snap!” Warrants urgent surgery to preventmuscle necrosis Long term double vision if missed May have little/no outward evidence ofinjury “White eye blow out” Oculocardiac reflex if muscle entrapped Slowed heart rate Nausea/vomiting Syncope/fainting

316
Q

What to do in the case of a chemical injury to the eye?

A

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

317
Q

What is the defintion of Fraility?

A

A person’s mental and physical resistance, or their ability to bounce back and recover from events like illness and injury

318
Q

Name the 2 models of fragility?

A

Phenotype modelCumulative deficit model

319
Q

What is the defintion of phenotype model of fraility?

A

Describes a group of patients characterises which, if present, can predict poorer outcomesGenerally individuals with three or more of the characteristics are siad to have frailityCharacteristics:- unintentional weight loss- reduced muscle strength- reduced gait speed- self-reported exhaustion- low energy expenditure

320
Q

What is the defintion of the cumulative deficit model for fraility?

A

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 outcomeSymptoms:- loss of hearing- low mood- tumourDisease:- dementia

321
Q

Name the 3 main factors which contribute to fraility?

A

DisabilityMultimorbidityBiological ageing

322
Q

What is the defintion of multimorbidity?

A

Multiple long term conditions - fraility may be masked due to the focus on their other long term diseases

323
Q

What are the downfalls in the NHS for fraility?

A

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

324
Q

Deacribe the comprehensive geriatric assessment - name the 6 factors?

A

PhysicalSocioecononic/environmentalFunctionalMobility/BalancePsychological/MentalMedication review

325
Q

Why is the comprehensive geriatric assessment successful?

A

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

326
Q

Explain the plan created after the comprehensive geriatric assessment

A

AssessmentCreation of problem listPersonalised care planInterventionRegular planned view

327
Q

How does ageism have an affect on the elderly

A

Associated with poorer physical and mental healthIncreased social isolation and lonelinessIncreased depressionGreater financial insecurity Decreased quality of life Premature death

328
Q

What is the defintion of delirium?

A

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 occur8-17% of A&E admissions for elderly

329
Q

What is the defintion of capacity?

A

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

330
Q

What must you consider to decide if a patient has capacity?

A

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

331
Q

How to explain things to patients with limited capacity?

A

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 personUse broad terms and simple language

332
Q

Explain the 2 strands to understanding for capacity?

A

There is having a grasp of the factsThe ability to weight up the options and forsee the different outcomes or possible consequences of one choice to another

333
Q

What is the defintion of limited capacity?

A

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

334
Q

What is the defintion of polypharmcy?

A

Five or more medications - use of multiple medications that are unnecessary and have the potential to do more harm

335
Q

Describe the deprescribing process of medications?

A

Review mefsIdentify inappropriate, unnecessary or harmfulPlan deprescribingRegularly review

336
Q

What are the symptoms of anticholinergic burden?

A

Symptoms:- brain - drowsiness dizziness, confusion and hallucinations- heart - rapid HR- bladder - urine retention- skin - unable to sweat- bowel - constipation- mouth - dry- eyes - blurred vision

337
Q

What is the defintion of anticholinergic burden?

A

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.

338
Q

Medications that have anticholinergic side effects?

A

AntihistaminesTricyclic antidepressantsAsthma drugCOPD drugs

339
Q

What other cause can cause fraility? And risk factors

A

Clostridium difficileRF:- antibiotics- advanced age- prolong hospital- ppi use- chemo- ckd- IBD- low vit d

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