Management Strategies for Patients with Physical and Learning disabilities Flashcards
What must be considered before carrying out operative dental treatment on patient with Physical and Learning disabilities?
Cooperation and Anxiety
-> can they accept treatment
-> will alternative modality be required
Safety/risk assessment
-> Medical, physical, emotional status
Social status- dependence, support, maintenance of dental treatment
What shoudlbe considered when determining the risk in patients with learning and physical disabilities?
Nature of disease
Severity
Control/stability of condition
Prognosis- end of life/palliative care?
Anxiety- may be medically based
Invasiveness
Adjuvants utilised- LA usually the safest but sometimes sedation/GA may be safer
Which behavioural management techniques can be useful when treating patients with learning and physical disabilities?
- Acclimatisation
- Tell, show, do
- Relaxation
- Structured time – can work well with A.S.D. but have to understand constructs
How can multiple shirt visits be structured when trying to acclimatise a patient?
Visit 1- Sit on the chair
Visit 2- Tooth brushing ( can allow you to have a look)
Visit 3 Exam
Visit 4- Radiographs
Visit 5- Small filling
Visit 6- Larger filling
Visit 7- Extraction
What are the advantages of conscious sedation in special care?
Avoids risks associated with GA
Can help with behavioural management
Patient may be able to tell you how they feel
Muscle relaxation- less involuntary movements
What are the disadvantages of conscious sedation?
If patient non-verbal it might require other assessment tools to check on them while they are sedated
Risk of
-> over sedation
-> respiratory depression
-> abnormal reactions- seen in ASD
What are the different types of sedation used in special care dentistry?
Oral- can be disguised as a drink
-> bolus dose- unpredictable pharmacology, slower onset
Intra-nasal
Inhalation
IV
What are the ADV/DIS of intranasal sedation?
ADV
-> Absorbed into nasal mucosa- quick onset
-> Avoids patient having to take medication orally
DIS
-> Access may be difficult
What are the ADV/DIS of inhalation sedation in special care?
ADV:
Least risky- even if very medically compromised/obese (breathing higher than air oxygen)
Assessment/treatment can be done on same day
Good for anxiety reduction
DIS:
Patient may not understand nasal breathing concept
Significant behaviour management required
Good cooperation required
Nitrous oxide is not environmentally sustainable
What are the advantages of IV sedation in special care?
Midazolam causes muscle relaxation and helps inhibit involuntary movements (good for CP and Huntingdon’s)
Broader range of treatment options available
-> crowns, bridges, endo (not available in GA routinely)
What are the disadvantages of IV sedation in special care?
Advanced mixing drugs technique- requires extra training
High risk for obese patients
Holding may be required
Post-op care required
Chaperone required
Must get patient home via private transport
May require multiple appointments
Requires cooperation- esp for cannulation
ASA 3 patients must be seen in hospital setting
Risk of respiratory depression
What are the risks of GA?
Death- 1 in 100,000/200,000
-> Risk increases with age, complexity of surgery, emergency surgery or very unwell before procedure, other co-morbidities
Brain damage
Lethargy/delayed recovery
Nausea/Vomiting- can persist for up to 24hours
Shivering- few mins to a few hours
Confusion and memory loss
Bladder issues- difficulty urinating
Dizziness- can be treated with fluids
Sore throat
Bruising and soreness- from procedure or cannulation
Anaphylaxis
Waking up during operation
When may GA be the best option for a patient?
Significant volume of treatment required
Patient is uncooperative
If significant medical complexity is evident patient can be managed in a controlled and safe environment with medical support
What is the aim when providing dental treatment for patients in special care under GA?
Render the oral health stable and predictable with little risk of symptomatic dental disease in the 2-3 years following that episode of treatment
-> minimising the need for repeat exposure to GA
What are the features of a dental treatment plan in GA?
- No crown and bridge unless extra-coronal can be placed without GA
- No endodontics (can be exceptions, strategic teeth in presence of good OH)
- Infected teeth and teeth with pulpal involvement are removed
- Teeth of poor prognosis may be removed
- Opposing non-functional teeth may be removed
What are the steps in GA? (part 1)
- Patients receive dental assessment
- Patient is called to pre-op medical assessment
- If suitable, will then attend hospital for General Anaesthetic
- Checked in
- Sees anaesthetics team
- Dentist confirms plan and ensures all paperwork in place
- Pre-med given if required
- Anaesthetics team provide care – Nasal tube for comprehensive care
Steps in GA (part 2):
Dental team
- Examination ( EUA)
- Radiographs
- Treatment planning
- Scale and Polish
- Restorations
- Extractions ( non-surgical and surgical)
Which other things may be done opportunistically while disabled patient is under GA?
Bloods
Hair cut
Toe nails cut
Ear wax removal
When should a patient with physical or learning disability be referred for treatment under GA?
Pain and swelling
-> where no alternatives but must be managed acutely
Obvious dental disease when no other modality is possible
If number of years since reasonable examination and suspicion of oral disease/poor OH
What are the advantages of keeping someone with a physical or learning disability as an in patient following GA?
Captive audience
Preparation of patient e.g. tests and products
Medical back up
Post-operative monitoring
Piggy-back for holistic care
What are the indications for GA in patients with physical or learning disabilities?
- Intellectual Impairment
- Multiple Disabilities
- Dental anxiety /Phobia
- Medical reasons – control
- Behavioural- uncooperative
What can cause a post-GA emergency in patient with physical and learning disability?
Bleeding
Not being able to achieve haemostasis
-> may require second GA in a session
Post-op infection
-> consider giving AB rather than second GA to manage
What can be done to buy time if the patient is uncooperative due to disability and has reversible pulpitis?
If some access possible- ART
Temporisation
What can be done to buy time if the patient is uncooperative due to disability and has irreversible pulpitis?
If access possible- sedative dressing
-> remember AB are not effective in managing pulpal inflammation
What can be done to buy time if the patient is uncooperative due to disability and has periapical infection?
Give antibiotics and plan for treatment by sedation/GA
What should be ascertained before treating dental trauma in patients with physical and learning disabilities?
Injury Classification
Level of cooperation
-> can intervention be done safely
Medical history
Dental History
-> previous treatment- LA, GA, sedation
-> caries experience
-> self care routines
What is the concept of shared care? (blending services)
Patients with mild impairment and disability can be cared for in primary care (GDP) services
Patients with moderate and severe impairment and disability may require more of their care provided by specialist services
Primary care professionals can ask specialist services to help with treatment planning, treatment, sedation/GA
*Those with most severe may only attend special care specialists (more time, better environment)
What are the benefits of primary care for patients with physical and learning disabilities?
- Proximity – financial, work, transport for person +/- carer
- Relationships may already be established
- Family members may attend practice
- Longitudinal care - Prevention and Follow up
- Equal opportunity to services
