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BDS4 BAMS Special Care Dentistry > Oral Healthcare for People with Physical and Learning Difficulties > Flashcards

Oral Healthcare for People with Physical and Learning Difficulties Flashcards

1
Q

categories of barriers to care for special care pts

4

A

user/carer
professional services
physical barriers
cultural barriers

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2
Q

user/carer barriers for SC pts

7 main types

A

Physical, mental and cognitive ability to carry out effective oral hygiene, diet, decisions and tx

Diet
* High calorie food
* Dry mouth
* Sugar based liquid medications
* Laxatives

Fear and anxiety
* Irregular attendance

Greater need for behavioural management, sedation and general anaesthetic services

Require support to attend dental appointments

Transfer of responsibility to adult and carers despite high level of support from dental teams

Knowledge, skills and attitudes of carer

Training required

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3
Q

professional services barriers for SC pts

5 main types

A

Low confidence in the management of people with LD by new graduates

Inadequacies in professional training for dentists and therapists

Dentists lack experience

Financial constraints due to NHS renumeration

carers belief dental services would prefer to see no-troublesome pts

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4
Q

physical barriers for SC pts

2 main types

A

access
* physical
* emotional
* cost

travelling distance for speciliast services

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5
Q

culutural barriers for SC pts

5 main types

A

Black and minority groups are subject to the same barrier but their experience is exacerbated by ethnicity

Language

Different attitudes to oral health

Gender sensitivities

communication of need

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6
Q

oral disease experience for people with a mild learning disability

A

Less research available as generally managed within the primary care setting

Those with mild learning disabilities are more likely to have filled teeth, fewer extractions and more untreated active decay than adults with more profound disabilities

Dental care received appears to be related to the individual’s ability to comprehend or co-operate with treatment

Fewer dentures provided
* Increased burden of denture related problems, when they do have them

COMMON RISK FACTOR approach

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7
Q

what is the common risk factor approach

A

group of people experience poor oral health, but there is common risk factors across many conditions and diseases.

Multiple factors involved – more likely to be in lower socioeconomic background therefore have more barriers to healthcare services

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8
Q

disability and oral health

link

A

**Disability exerts an indirect effect on oral health by increasing people’s risk for developing dental disease. **

Examples:
* People who take multiple medications may experience a dry mouth that increases cares risk
* People with physical impairment may find it hard to clean their teeth or go to the dentist regularly

Oral health issues are often overlooked in health and social care planning for disabled people, because of lack of awareness amongst teams of how to protect oral health or the potential impact on oral health of medications prescribed or dietary advice given.

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9
Q

factors to consider when delivering oral healthcare to ensure to get it right

3

A

place
time
person

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10
Q

factors in deciding right place for delivery of care

3

A

Where and when is assessment appropriate?
What tx is safe and feasible in different care environments?
What if a medical emergency or complication arises?

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11
Q

options for care setting

4

A

Own Home,
Hospital Ward (e.g. multiple medical issues making them ASA III),
Primary Care,
Secondary/Tertiary Care

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12
Q

access details to ensure known before SC pt comes in

barriers and facilitators
3 categories for access

A

Location of site
* Distance and safety of transport

Moving and handling
* Training and equipment e.g. hoist (let trained individuals do it)

Medical support available
* Accessing the right facility

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13
Q

facilitators for access to dental setting

6

A
  • Ground floor access
  • Suitable car parking
  • Elevators
  • Hand rails
  • Wide corridors
  • Disabled toilets
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14
Q

3 facilitators for access to dental chair

A
  • Banana board
  • Wheelchair chair
  • Hoisted in – if they cannot weight bear themselves – do not attempt to lift/aid them
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15
Q

6 facilitators for access to the mouth

A
  • Bedi shield
  • Open wide mouth rests
  • Toothbrush – can be good aid initially to build up rapport, as they’ll likely recognise what a toothbrush is
  • Mirror (ensure non shattering)
  • Good light
  • Head support – ask consent
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16
Q

factors to consider it is the right time for delivering dental care

5

A
  • environmental
  • medical disease
  • social context
  • transport
  • dental disease need
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17
Q

person options for delivering of dental care

A

GDP - primary care
dental officer (commplex)
specialist/senior dental officer (very complex)
consulanat (most complex)

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18
Q

clinical holding

A

*assist or support a pt to receive clinical dental care or tx in situations where their behaviour may limit the ability of the dental team to effectively deliver tx, or where the pt’s behaviour may present a safety risk to themselves, members of the dental team or other accompanying persons

Gradient control
* Nature of hold applied should be proportionate to the actions / behaviour of the person and the risks associated with the behaviour
* If too forceful, too restrictive or sustained for extended period of times the person is likely to become distressed
* If not supportive enough the person may become anxious or unsafe

Consider care and support
Record keeping
engagement and learning

ask consent first
not commonly done in UK

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19
Q

7 things to assess gage indivduals learning disability level

A
  1. Level of understanding and intellectual function
  2. Communication
  3. Physical and emotional access
  4. Co-operation
  5. Medical Status
  6. Social Status
  7. Dental Status
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20
Q

how to attain C/O and HPC

A

From the patient if possible
From the carer if not possible to gain

Remember symptoms and signs which maybe indicative for people who cannot reliably report or communicate
* Sleep interruption
* Changes in behaviour
* Rubbing of an area
* Pulling at an area

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21
Q

common medical conditions in SC pts

9

A
  • GI cancers
  • Epilepsy
  • GI problems
  • Anxiety disorders
  • Respiratory disorders
  • Sensory impairments
  • Obesity
  • Diabetes
  • Coronary heart disease
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22
Q

things to check when getting medical hx of possible SC Pt

A

Intellectual Impairment
As part of a syndrome with other associated conditions: Down syndrome, Fragile X, Williams syndrome, Autistic Spectrum Disorders ( not all people have a L.D.)

Cerebral Palsy ( not all people have a L.D.)

Epilepsy +/- neurological conditions Diabetes

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23
Q

SHx check

6

A

Smoking/alcohol
Living arrangements
Support
Transport
Access facilitators required
Consent and capacity

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24
Q

DHx check

6

A

Cooperation
Preventative regime (what? How much? When?)
Level of support
Diet and method of delivery (what? How much? Nil by mouth?)
Swallowing of thickeners if appropriate
Previous delivery of dental tx (sedation? GA?)

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25
Q

how to conduct an exam on SC pt

A

Extra-oral… if you can

Intra –oral
* May only be brief look
* Multiple looks for each quadrant
* Use counting
* Use access aids
* Use other people if possible
* If using supportive holding always gain consent and document it!

Look at soft tissues, caries and oral hygiene

If possible assess periodontal condition
* Likelihood of BPE?
* Mobility might be a more acceptable assessment

There is an element of compromise
Document everything that was assess and everything that was not! Justify

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26
Q

how to tx plan after exam of SC pt

A

Are special investigations required?
* Can you achieve them?

Findings will dictate what needs to be managed

**Prevention

Modification of risk factors **

Treatment
a. Emergency – if required
b. Short, middle and long term thinking
c. How, where and who?
d. Share care and modalities?
e. Role for hygiene/therapy in maintenance care

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27
Q

5 things to consider when tx planning SC pt

A

a. Emergency – if required
b. Short, middle and long term thinking
c. How, where and who?
d. Share care and modalities?
e. Role for hygiene/therapy in maintenance care

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28
Q

to demonstrate capacity indivduals should be able to

4

A

Understand in simple language what the treatment is, its purpose and nature and why it is being proposed

Understand its principle benefits, risks and alternatives

Understand in broad terms what will be the consequences of not receiving the proposed treatment

Retain the memory of the decision

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29
Q

2 principles of the Adults with Incapacity Act

2000

A

Principle 1 – Benefit
Principle 2 - Least restrictive option
Principle 3 - Take account of the wishes of the person
Principle 4 - Consultation with relevant others
Principle 5 - Encourage the person to use existing skills and develop new skills

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30
Q

principle 1 of the Adults with Incapacity Act

2000

A

benefit

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31
Q

principle 2 Adults with Incapacity Act

2000

A

least restrictive option

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32
Q

principle 3 Adults with Incapacity Act

2000

A

take account of the wishes of the person

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33
Q

principle 4 Adults with Incapacity Act

2000

A

consultation with relevant others

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34
Q

prinicple 5 Adults with Incapacity Act

2000

A

encourage the person to use existing skills and develop new skills

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35
Q

augmentative communication aids examples

4

A

picture boards - allows them to show what they feel about things, point to pictures

social stories

talking mats

makaton

ask them to bring any aids they use with them to appt

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36
Q

multidisciplinary care for SC pts

A

Pt in centre
* Carer
* Oral health team
* Dietician
* Speech and language therapist

most common in oncology, but used in other areas of care too
Work with colleagues to target that oral health care is not in isolation

Common risk factor approach for other medical conditions

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37
Q

how to use the fact an individual is independent to your advantage

2

A

Maximise existing skills
Establish a routine

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38
Q

how to use the fact pt is dependent on others to your advantage

4

A

Who is responsible
Can you engage them
Provide appropriate education
Facilitate support

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39
Q

what can be the cause of a pt drooling

5

A
  • Developmental disability
  • Cerebal palsy
  • Progressive neurological conditions
  • Parkinson’s disease
  • Motor neuron disease

Rare to that they are producing excess saliva

40
Q

how can drooling be managed

3 pathways

A

Head Positioning and Posture
* Neuromuscular
* Try and correct forward positioning where possible

Speech and Language Therapy:
* Behavioural techniques
* Oral Sensory –Motor Intervention

Medication and Surgery (extreme measure)

41
Q

dysphagia is

A

difficulty in swallowing

42
Q

issues due to dysphagia

A

affects pt ability to maintain good OH effectively

Hospitalisation

Dependency can affect stroke patients’ ability to maintain oral hygiene effectively

Increased exposure to antibiotics

Dehydration and xerostomia can be a particular problem because of:
* Oxygen therapy
* Mouth breathing
* Side-effects of medications
* Reduced food and fluid intake

43
Q

pouching
what is it
impact

A

Food or medicines are kept in buccal sulcus
* Check on examination if anything there – can cause cervical/root caries, ulceration due to medication (aspirin, alendronic acid)

Moderation of consistency of foods and liquids

Nutritional changes and sip feeding (inc caries risk)

Risk of aspiration

44
Q

altered texture of foods indicates

A

ability to swallow

45
Q

position to perform OH/support someone with OH

A

sitting upright

NOT TILTED BACKWARDS, less likely to inhale

46
Q

oral care and dysphagia

A

Support from carers and nursing staff
If possible sit the patient in an upright or semi upright position for toothbrushing
If the patient is able to spit out following mouth care this should be encouraged
Hand-over-hand technique with the patient
Regular dry mouth care
Use the handle of a second toothbrush to improve access to the whole mouth.
A mouth guard or finger prop may also be useful
Consider adaptations to toothbrush handle
Use suction if you are trained to do so

47
Q

PEG fed, do they still need OH?

A

YES

Tube direct to stomach

Still have biofilm development in mouth
* Can additionally still get tasters/drinks etc
* Still a risk for dysphagia as well

48
Q

caution with tasters

A

Taster tends to be sweet
Likely also have dry mouth
Discuss what they have and when

49
Q

possible modfications to the handle so the pt can be part of their OH routine

A
  • Ball ended
  • Putty grip (or heat cure acrylic)
  • Toothbrush with multiple heads
50
Q

toothpaste options

A

Level of fluoride as per risk assessment

If suggesting foaming toothpaste assess ability to swallow

Non-foaming toothpastes better for risk of aspiration or pt dysphagic (SLS free)

Unflavoured toothpastes – Oranurse (sensory issued)

51
Q

what is Open Wide

A

public health improvement project, for middle part of life (broad – stroke, LD)

  • Patient centred / Client centred
  • Tailored to each individual’s needs
  • Maximising the capabilities of the individual
  • To provide support where required in the most appropriate way

A training resource and manual for the delivery of oral care for people with additional care needs
Open Wide consists of three units:
* Unit 1 – Core Oral Health Knowledge
* Unit 2 – Practical Oral Care
* Unit 3 – Oral Health Documentation

52
Q

communication skills for SCpts

A
  • Be caring, calm and friendly. Smile.
  • Talk clearly, at the individual’s pace.
  • Use the communication technique that works for the person
  • Explain in short sentences and in simple terms what you are doing.
  • Use reassuring and appropriate body contact and gentle touch.
  • Consent before – ‘if its alright with you can I perform check you cheeks and necks to see if how it feels?’
  • Remain positive and try not to show any frustratio
53
Q

basic guide to support OH of SCpt who able to perform

A

Discuss at eye level from in front of the person

Pea-sized amount of toothpaste on small headed toothbrush

Access to the mouth
Systematic approach:
Outside surfaces,
Inside surfaces
Chewing surfaces
Mucosa

Counting, singing

Timing
* Best time of day
* Same time of day to develop a routing
* Predictable
* Routine can be positively reinforced

Environment
* Dignity / embarassment
* Light to be able to see

54
Q

bridging
behavioural strategy

A
  • This helps to engage a person with the task through their senses and helps them to understand the task.
  • Describe and show them the toothbrush, then mimic brushing your own teeth.
  • Give another toothbrush to the individual. They may mirror your behaviour and brush their own teeth.
55
Q

chaining
behavioural strategy

A

involves gently bringing the person’s hand to their mouth while describing the activity. The carer starts the activity and the individual finishes it .

56
Q

hand over hand
behavioural strategy

A

chaining is not successful, then place your hand over the individual’s hand and gently brush their teeth together

57
Q

distraction
behavioural strategy

A

Distract the individual by placing a familiar item in their hand while you brush their teeth.

Other distraction such as music may be helpful.
* Brush DJ – song whilst performing OH can be useful

58
Q

rescuing
behavioural strategy

A
  • If attempts are not going well, the carer can leave and a ‘rescuer’ comes in to take over.
  • Bringing in someone else with a fresh approach may encourage the individual to cooperate
59
Q

how to deal with a toothbrush biter

A

Allow the person to continue biting on one toothbrush
Use another toothbrush to provide oral care

60
Q

how to deal with a tongue thruster

A
  • If the person’s tongue moves around a lot, or their lips are pressed tightly together, this may push the toothbrush out of their mouth or away from their front teeth.
  • Use a gauze square wrapped around your forefinger to gently retract or hold back the tongue or lip.
  • This will need patience and perseverance.
61
Q

how to deal with a tongue thruster

A
  • If the person’s tongue moves around a lot, or their lips are pressed tightly together, this may push the toothbrush out of their mouth or away from their front teeth.
  • Use a gauze square wrapped around your forefinger to gently retract or hold back the tongue or lip.
  • This will need patience and perseverance.
62
Q

how to introduces a toothbrush to someone who is resistant

A

Small head

Soft toothbrush

dry toothbrush

flavouless non foaming F toothpaste

Toothbrush with meaning
E.g. I’ll use a red toothbrush in the top right area, then move to the yellow toothbrush for top left etc

63
Q

pt seems resistant to oral care - what to do

A

ask why

64
Q

pt seems resistant to oral care - what to do

A

ask why

65
Q

pt has bleeding gums

A

Reassurance

Must provide oral hygiene advice – brush through bleeding

If still not resolving then seek an opinion

66
Q

sensory aids for oral care

A

Oral Care is a Sensory Experience :
* Power Suit
* Use of sensory aid prior to brushing to destress and afterwards e.g. Stress ball
* Desensitisation - build up
* Counting
* Find a brush which is something they are interested in - football team, game etc
* Warm water
* Stories or Books

67
Q

denture hygiene advice

A

Dentures must be removed form the mouth
* Reduces the risk of oral mucosal disease

Rinse dentures after every meal.

Clean dentures morning and night using a toothbrush and denture cream, or plain soap and water.
* Do this over a filled basin or a soft surface to reduce the risk of breaking the dentures if you drop them.

Soak dentures in disinfecting solution for at least 20 minutes once a day.

Soak dentures overnight in plain water

68
Q

denture hygiene advice

A

Dentures must be removed form the mouth
* Reduces the risk of oral mucosal disease

Rinse dentures after every meal.

Clean dentures morning and night using a toothbrush and denture cream, or plain soap and water.
* Do this over a filled basin or a soft surface to reduce the risk of breaking the dentures if you drop them.

Soak dentures in disinfecting solution for at least 20 minutes once a day.

Soak dentures overnight in plain water

69
Q

how to make oral care a positive habit

the habit loop

A

Habits need a cue /trigger
* Time of day
* Environment
* Object
* Preceding behaviour
* Person

Repetition
* To become habit, it can take 18 days (2.5 weeks) - 254 days (over 8 months) to embed a new habit.
* Mean number of days for change = 66 days.

Rewards

70
Q

ways to facilitate behaviour change

7

A
  • Supportive environments
  • Stable environments
  • Leverage the status quo – intervene in major change
  • Piggyback – can it be added onto an already positive experience
  • Make it easy – don’t move mountains
  • Unique personalised cues
  • Practice and repeat
71
Q

what happens when indivdual in residential care

A

oral health assessment within 48hrs (risk assess and ID oral health risks and needs)

oral care plan - completed by carer when task complete, checked weekly by senior staff, reviews every 4 weeks

72
Q

what is Disiability Distress Assessment Tool (DisDAT)

A

Distress is a useful clinical construct in providing care
DisDAT reflected patients’ distress communication identified by a range of carers
Provided carers with evidence for their intuitive observations of distress.
Method through which to understand the individual’s language of distress
Useful tool to identify an individual’s usual content cues, thus enabling distress cues to be identified more clearly
It is the first step in the journey ………..

  • Observe the person
  • A number of people
  • Over a period of time
  • Associated clinical decision checklist
73
Q

3 thinsg to consider when planning operative dental tx for special care pt

A

Cooperation and anxiety
* Can they accept care
* Modality of tx

Safety and risk assessment
* Medical status
* Physical status/ disability
* Emotional status

Social status
* Dependence
* Support
* Maintenance of dental tx

74
Q

determining risk of medical disease

involves

A

Evaluation of all risk factors

Medical risk
* Nature of disease
* Severity
* Control/stability
* Prognosis
* Effect tx plan and modality of any tx

Dental risk
* Anxiety
* Invasiveness
* Adjuvants utilised
* Sedation options (ASA class)

75
Q

behaviour management techniques

7 exammples

A
  • Acclimatisation
  • Tell, show, do
  • Relaxation
  • Structured time – can work well with A.S.D. but have to understand constructs
  • Multiple short appointments in staged approach
  • Consider behavioural change and wider context when making treatment planning decisions
    * Build of rapport and trust can be key
76
Q

examples of how to stage short appts to get throught tx plan

A

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

77
Q

sedation in SCD

A

Sedation is a valuable tool in the management of people with physical and learning disability
* But risk assessments for each type must be undertaken on individual basis

Avoids the risks associated with general anaesthetic

Different set of skills required in assessment when compared to purely dentally anxious individual

Patient ability to tell you how they feel may not always be present so other assessment tools are required
* May not be able to communicate verbally with you initially

However, is not risk free particularly with the use of benzodiazepines: (can be unpredictable)
* Over sedation
* Respiratory depression
* Abnormal reactions

78
Q

4 types of sedation

A

oral
intra nasal
inhalation
IV (dentist led or anaesthetist led)

79
Q

oral sedation

A

Patient is still required to take medication
Can be disguised in a drink
Can be unpredictable (bolus dose, pharmacodynamic / pharmacokinetics can vary hugely with this population group)

80
Q

intranasal sedation

A

Increasingly used
overcomes patient having to take medication orally
Relatively quick onset in comparison to oral

81
Q

inhalation sedation

A

Can be contraindicated as patient requires the understanding to be able to breath in and out through the nose piece
Least risk associated with this modality (30% NO, 70% O2 still more than atmospheric; environmental cost/sustainability side of nitrous oxide)
Significant behaviour management required

82
Q

intranasal (dentist or anaesthetist led)

A

In most cases utilises midazolam
Drug can be titrated safely to maximum effect
Risk of respiratory depression
Significant benefits with muscle relaxation / involuntary movement
* Huntington’s Disease, Cerebral Palsy

83
Q

when is inhalation sedation useful

6 scenarios

A
  • Anxious pt
  • Medical risk modified by stress
  • Level of co-operation is important
  • Assessment on same day
  • Margin of risk if very minimal
  • Even in the most medically compromised this technique is an option
84
Q

pros of IV sedation

2

A

Cost-effectiveness - debate
Broader range of treatment options (compared to GA – tends to be more radical)
titrated drug to maximise effect
muscle relaxation - good for Huntington’s, cerebral palsy

85
Q

cons of IV sedation

5

A

Co-operation for assessment and ASA status (I or II dental, III hospital)

Co-operation for cannulation

Paradoxical reactions

Requires 24 hour post op responsible person for 1 on 1 care

May require multiple appointments

May give NO place cannula, then stop NO and start titration IV drug

86
Q

risk associated with GA

A

Death - 1 in 100,000 - 1 in 200,000

Risk increases with age, complexity of surgery, emergency surgery or very unwell before procedure

Brain damage, Nausea and vomiting, Lethargy, delayed recovery etc.

Increasing complexity associated with increasing co-morbidity – increased risk

Medical status – All human systems must be evaluated to determine level of risk

Social status – treated as an inpatient or an outpatient? Is it safe for them to go home?

87
Q

risks to warn pt/carer of for GA SCpt

A

Feeling sick and vomiting – this usually occurs immediately, although some people may continue to feel sick for up to a day

Shivering and feeling cold – this may last a few minutes or hours

Confusion and memory loss – this is more common in elderly people or those with existing memory problems; it’s usually temporary, but occasionally can be longer lasting

Bladder problems – you may have difficulty passing urine

Dizziness – you will be given fluids to treat this

Bruising and soreness – this may develop in the area where you were injected or had a drip fitted; it usually heals without treatment

Sore throat

*Allergic reaction to the anaesthetic (anaphylaxis) uncommon

Waking up during your operation*

88
Q

3 situations when GA best options

A

a. Significant volume of treatment
b. Patient is uncooperative
c. If significant medical complexity is evident patient can be managed in a controlled and safe environment with medical support

89
Q

tx plan tends to be what when go for GA tx

A

More severe treatment plans:
* 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 – prevent overeruption and causing issues later

Render the oral health stable and predictable with little risk of symptomatic dental disease in the 2 – 3 years following that episode of treatment, thus minimising the need for repeat exposure to GA

90
Q

what happends when pt seen for GA

A

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!

Dental team
* Examination (EUA)
* Radiographs
* Treatment planning – quick, think now and long term
* Scale and Polish
* Restorations
* Extractions ( non-surgical and surgical)
* +/- others e.g. Bloods, hair cuts, toe nails cut, ear wax removal etc.

91
Q

when to refer

3 situations

A
  • Pain and swelling and swelling where no alternatives exist but must be managed acutely
  • Obvious dental disease when no alternative treatment modality is possible to facilitate dental care
  • A number of years since a reasonable examination in the presence of poor oral hygiene and suspicions of disease

The individual with good oral hygiene and no obvious dental disease does not require a regular GA for examination !!!!

Local criteria available

92
Q

basic prinicples of dental emergencies for uncoop pt

A

buy time

93
Q

revesible pulpitis and uncoop pt
how to manage

A

Can you gain enough access for ART ? (atraumatic restorative technique)
Or temporisation (GI)

94
Q

irrevsible pulpitis and uncoop pt
how to manage

A

Can you gain enough access to place a sedative dressing? (ledermix)
Antibiotics are not effective in the management of pulpal inflammation

95
Q

periapical infection and uncoop pt
how to manage

A

Antibiotics and plan for the future – sedation or G.A.

96
Q

benefit of SC pt being seen in primary care

6

A
  • Learning disability is more common in families of a lower socioeconomic status
  • 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

BDS4 BAMS Special Care Dentistry (5 decks)

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