OSCE DOC - Special care and PMHP Flashcards
Chemotherapy (6 mins)
50-year-old patient about to begin chemotherapy for breast cancer.
No idea of need to go to dentist for assessment but oncologist sent her to you as her GDP.
Explain the relevance of dental health for cancer treatment, diagnose a condition of a tooth (gross caries / apical periodontitis from radiographs) and your proposed management.
Talk about getting them dentally fit, improving their OHI and looking after their oral health:
Chemotherapy puts a toll on the entire body, including the mouth
GDP attempt to reduce complications in chemotherapy regime
- avoid unscheduled interruption of chemotherapy regimen
- remove potential sources of infection
- avoid exacerbation of mucositis
Finally, plan prevention and rehabilitation
Explain that chemo increases chances of infection, delayed healing, ulcers, altered taste, and patient will have dry mouth which will further contribute to problems
Treatment to be carried out:
Full clinical exam and radiographs (OPT / PA)
Full mouth scaling
Remove any dubious prognosis teeth or areas of possible infection
- normally XLA needed- 10 days to heal
- should not be done during chemo due to high risk of infection
- if done after chemo- again higher risk of infection, slower healing, risk of MRONJ
Impression for soft splint
Smooth down sharp teeth
Start fluoride therapy
Pre-treatment prevention:
Oral hygiene
- 2x brushing daily at least 2 mins
- prescribe 2800ppmF duraphat (0.619%)
- interdental cleaning- specifically instruct how to use
Fluoride therapy
- fluoride varnish, Duraphat toothpaste, trays to fill at night
Diet advice
- avoid spicy and hot foods, avoid fizzy drink, fruit juices, acidic fruit
Smoking and alcohol advice if relevant
Mid-treatment management:
Minimal role unless emergency +/- manage pathology
Mucositis management
- inflammation and ulceration, severe pain requiring analgesia, impacts on eating and oral hygiene
- general- avoid smoking, spirits, spicy foods, tea, coffee, non-prescription medicine; topical- oral cooling prior therapy, ice, topical lignocaine, saline, sodium bicarbonate, benzydamine hydrochloride, gelclair, caphasol, tea tree oil mouthwash
Remove potential sources of infection
Candidosis- pseudomembranous candidosis (thrush)- treat with antifungals
Deal with oral ulceration- mucositis, candida, viral infections (reactivation of herpes)
Post-treatment palliative care:
Maintenance of oral and dental health- increased frequency of check-ups
Prevention- diet, OH, fluoride, smoking cessation
Monitoring- increased frequency check-ups, pros maintenance
MRONJ risk
Altered taste
Dry mouth
- decreased salivary flow- 50-60% in first week, and further 20% in next 5-6 weeks
- change in salivary consistency and character, increased viscosity, decreased Ph
- change in taste perception
- recovery over period of years, will not return to normal
- associated problems- dysphagia, dysarthria, dyspepsia, quality of life
- increased risk of caries, perio, candidiasis, sialadenitis, prosthodontic difficulties
Trismus
What can a dentist do pre-treatment to help make a patient dentally fit before chemo. Including treatment and advice.
Role of dentist Pre-Cancer treatment- make patient dentally fit
* Definitively restore carious teeth
* Removal of trauma: adjust sharp edges on teeth/dentures
* Impressions: construct fluoride trays, soft splints
* Denture hygiene and instructions to avoid infection during cancer treatment
* Extract teeth with dubious prognosis no less than 10 days before starting cancer
treatment
* Full mouth scale
* Antibiotic prophylaxis if neutrophils are low and planning invasive treatment – liaise
with medics
* Orthodontics: discontinue and remove fixed appliances
* Smoking and Alcohol advice
* Restorative: Study casts for implant planning, pre-treatment records, planning for
trismus
* Encourage enhanced prevention- duraphat toothpaste
* Inform patient that they will only receive maintenance care during treatment, in case
of emergency liaise with cancer team
Side effects of chemotherapy?
Side effects of chemo
* Mucositis
* Dry mouth
* Altered taste
* Re-activation of viruses- herpes and zoster
* Candidal infections- opportunistic due to low immune system
* Delayed healing
* Increased infection risk
Side effects of Radiotherapy:
Side effects of Radiotherapy:
* Trismus- fibrosis of tissues
* Dry mouth and radiation caries- rapidly progressing at cervical margins and incisal
edges
* ORN (if dose over 60mGy)- exposed bone at irradiated site (>3 months)
Give smoking cessation advice to a patient going through 5A’s.
Ask:
* Do you smoke?
* What do you smoke?
* How long have you smoked for?
* How many cigarettes a day?
* Why do you smoke?
* Does anyone in the family smoke?
* Any children in the house?
Advise:
* Smoking is harmful to general health (CVS, respiratory)
* Smoking is detrimental to oral health (tooth loss, reduced healing, staining, periodontal disease, oral cancer, implants, keratosis, lichen planus, delayed healing after extractions)
* Personal (money, bad breath)
Assess:
* Are you interested in quitting?
* Ask about motivations to quit
* Have you tried quitting in the past?
* Why were you not successful? What worked?
Assist:
* Would you like any help from the local stop smoking services?
* These increase likelihood of quitting by 4 times
* NRT- best evidence base- Champix, patches, gum
* E cigarettes- don’t know all side effects, still have respiratory effects, but less harmful than tobacco, no long-term health data
Arrange follow up and Refer:
* Local cessation services- pharmacy, GP, smokeline
* Self-referral- 0800 84 84 84
* Run by NHS24 and staffed by trained advisors
Offer written material
* Arrange follow-up
Actor marks
Non-judgemental, clear and easy to understand advice, good eye contact, open body language
Breaking Bad News (6 mins)
SSC- Give results of biopsy confirming oral cancer
Marks:
1. Student listens and is empathetic
1. Asks patient what patient is expecting from appointment
1. Asks permission to continue findings
1. Breaks news slowly in chunks
1. Avoids jargon, or explains if used
1. Allows patient time to take in information and gives chance to ask questions
1. Repeats the news
1. Summarises what they’ve said
1. Gives patient information on plan moving forward
1. Actor asked if they understood, been shown empathy
Setting
Ask patient what they are expecting from appointment
Sitting down at same level as them
Did they bring someone with them?
How have they been since you last saw them?
Perception
What does the patient understand has happened up until now?
- ‘Are you aware of what we’re here to discuss today?’
- ‘Do you know what the purpose of your biopsy was?’
- ‘Could you explain to me your understanding of things up till now?’
Information
Inform patient that you have the results of the biopsy
Ask them if you would like you go through the findings with them
Knowledge
Give a warning shot
- ‘I wish I had better news’
- ‘I am afraid the news is not good’- pause for a bit
Give them the knowledge of what you know
- ‘The test we have done has shown some abnormalities in the cells’- pause
- ‘Mrs Smith I’m afraid to say that you have mouth cancer’- big pause
Let this sink in, and let them dictate the pace of the conversation from here
- They might want to know loads of info really quickly or they might be in shock
- Give them a chance to ask questions
Empathy
‘I am deeply sorry to break this to you’
‘I understand that you must have lots of questions… do you have anything that comes to mind?’
‘Perhaps you would like to bring your husband in with you?’
Summary and close
Repeat news
Summarise what you’ve told them and the plan for going forward
- ‘The good news in all of this is that we’ve acted quickly and will be able to move forward with treatment as soon as possible’
- I’ll be speaking to the surgeons today and they’ll be seeing you in the coming week to discuss treatment’
Ask the patient if they understand and show empathy
I understand that this isn’t the news that you wanted and there has been a lot of information put upon you today. I want you to take time and speak with friends and family and if you have any further questions, please don’t hesitate to contact me.
Offer them a follow-up appointment or phone number for any questions
Give written material if available
What are some risks of oral cancer?
Risk factors for oral cancer:
Tobacco – smoke and smokeless (betel quid)
Alcohol
Human papilloma virus HPV16
Previous cancer
Family history of SCC
Sun exposure
Diet low in nutrients – fruit and veg
Malnourished
Immunocompromised – HIV/AIDs, GVHD
Lichen planus
Poor oral health
Complaints Procedure (12 mins)
Patient annoyed they had to wait an hour and receptionist was rude.
How would you address the patients complaint and then deal with this upset patient.
Take concerns seriously, answer questions as able:
* ‘Hello there, what seems to be the problem?’
* ‘Can I offer some assistance?’
Acknowledge anger:
* ‘I can see that you’re upset, and I am sorry that you feel this way’
* This does not accept blame
* DO NOT ACCEPT BLAME
Try to offer practical help:
* Offer investigation with receptionist and provide feedback to the patient
* If you can offer another appointment- ‘do you still have time for us to see you?’
* ‘What would you like you do, we can work around you?’
Making an apology:
* Be honest
* Explain how it happened
* Express remorse: deep guilt, express it (I am so sorry)
* Ensure amends: ‘is there anything we can do?’
* If formal complaint requested, advise on NHS complaints procedure:
Then, if required:
* a local resolution (payout)
* If satisfactory: complaint closed
* If unsatisfactory: healthcare commission or health service ombudsman
The NHS complaints procedure:
* Acknowledge the complaint and provide the patient with the practice complaint procedure
* Inform the dental defence organisation if you require advice
* Inform the patient of timescales and stages involved
* Acknowledge the complaint in writing by email or by telephone as soon as you receive it- 3 working days maximum, but ideally within 24 hours
* Early resolution 5 working days for issues that are straightforward and easily resolved, requiring little or no investigation (on the spot apology, explanation or other action to resolve complaint; either addressed by staff or referred elsewhere; complaint details, outcome, action recorded and used for service improvement)
* Investigation 20 working days for issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’ (definitive response provided following a thorough investigation of the points raised; responses signed off by senior management; senior management has active interest in complaints and use of info gathered to improve services)
* Independent external review ombudsman for issues that have not been resolved (complaints progressing to Ombudsman thoroughly investigated by board / service provider; Ombudsman assessed whether there is evidence of service failure, maladministration and issues in respect of clinical judgement; Ombudsman also assesses how complaint was handled by board / service provider)
* (Patient can approach local Health Board if they do not wish to complain to practice directly. Health Board acts as ‘honest broker’ to facilitate communication between patient and practitioner but has no responsibility to investigate complaints.)
What is the NHS complaints procedure?
The NHS complaints procedure:
* Acknowledge the complaint and provide the patient with the practice complaint procedure
* Inform the dental defence organisation if you require advice
* Inform the patient of timescales and stages involved
* Acknowledge the complaint in writing by email or by telephone as soon as you receive it- 3 working days maximum, but ideally within 24 hours
* Early resolution 5 working days for issues that are straightforward and easily resolved, requiring little or no investigation (on the spot apology, explanation or other action to resolve complaint; either addressed by staff or referred elsewhere; complaint details, outcome, action recorded and used for service improvement)
* Investigation 20 working days for issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’ (definitive response provided following a thorough investigation of the points raised; responses signed off by senior management; senior management has active interest in complaints and use of info gathered to improve services)
* Independent external review ombudsman for issues that have not been resolved (complaints progressing to Ombudsman thoroughly investigated by board / service provider; Ombudsman assessed whether there is evidence of service failure, maladministration and issues in respect of clinical judgement; Ombudsman also assesses how complaint was handled by board / service provider)
* (Patient can approach local Health Board if they do not wish to complain to practice directly. Health Board acts as ‘honest broker’ to facilitate communication between patient and practitioner but has no responsibility to investigate complaints.)
Communication (6 mins)
You overhear a nurse bad-mouthing a patient to a colleague in a public space in the surgery. They refer to them in a derogatory manner and joke about potentially posting this on social media. The patient and family are easily identifiable from the information discussed. Discuss this issue with your nurse.
FIONA R.
Introduce yourself
* And ask the nurse if it is okay to sit down with you
* ‘Do you have a minute to talk?’
Facts
* Facts of the situation- what, when, where, how?
* Ask the individual for their account of the situation
* ‘Unfortunately, there were remarks said publicly and a talk about posting on social media. I was wondering if you knew anything about this?’- allow nurse to reply
* ‘Is it okay if I hear your side of the story?’
* ‘Is it okay if I hear a bit more about that conversation?’
Issues
* What is the issue here?
* Explain the issue to the individual and why it is bad
* Quote GDC standards- i.e., breach of confidentiality, brings profession into disrepute
* ‘I know it may have been misjudged, but, unfortunately, it is not acceptable to say things publicly about patients or post things on social media’
* ‘As the GDC standards state, it is our obligation to have patients’ best interests in mind and to protect their information. Speaking in the public can breach confidentiality. The patients are recognisable from the posts and this is not protecting them. For example, if it was someone speaking / posting about your family member, how would you feel?’
* ‘It is also not providing the public with confidence in you, us and the profession. The practice could be in question and the GDC could be informed of this in future’
Options
* If involves patient, what options are there to manage this event- short, medium, long term
* What is in the patient’s best interest?
* ‘There are a few options to rectify this…’
* - ‘If there is a social media post- delete it and any photographs immediately’
* - ‘Apologise to the patient’ if still around (if not, the practice can contact patient to ideally attend for a formal apology)
Now
* What issues do we need to deal with right now?
* Inform the nurse that this shouldn’t happen again
Ask / advise
* Ask the individual if they would be willing to undertake training or education on this matter
* - ‘It would acceptable if we had training on this in the future and have meetings about social media to increase awareness’
* - ‘Would you be willing to have training on this?’
* If problem repeats
* - Get advice from someone more senior (defence union, VT trainer) how to manage this
**Record
Document conversation **
Breaking Bad News (6 mins)
Unrestorable 11 requiring XLA
A 28-year-old female patient who works in television has had an accident in which she injured her face.
There are no other injuries and you have completed the examination as well as taken a radiograph.
You have diagnosed the tooth as having a vertical root fracture and is unrestorable.
Explain your findings to the patient and how you would treat them.
Marks:
1. Student listens and is empathetic
1. Asks patient what patient is expecting from appointment
1. Asks permission to continue findings
1. Breaks news slowly in chunks
1. Avoids jargon, or explains if used
1. Allows patient time to take in information and gives chance to ask questions
1. Repeats the news
1. Summarises what they’ve said
1. Gives patient information on plan moving forward
1. Actor asked if they understood, been shown empathy
Setting
Sitting down at same level as them
Try to make them as comfortable as possible
Perception
What does the patient understand has happened up until now?
- ‘Are you aware of what might be wrong?’
What is the patient expecting from the appointment?
Information
Inform patient that you would like to discuss the prognosis of the tooth
Ask them if they would like you to discuss this
Knowledge
Give a warning shot
- ‘I wish I had better news’
- ‘I am afraid the news is not good’- pause for a bit
Give them the knowledge of what you know
- ‘Your tooth is unrestorable and requires an extraction’… pause…
Let this sink in, and let them dictate the pace of the conversation from here
- They might want to know loads of info really quickly or they might be in shock
- Give them a chance to ask questions
Empathy
‘I am deeply sorry to break this to you’
‘I understand this must be hard for you’
Summary and close
Repeat news
Summarise what you’ve told them and the plan for going forward
- ‘We will aim to replace this tooth as soon as possible for you’
Immediate options
- Immediate denture in the short term, then extraction
- Bridge using their own sectioned crown if available
- Direct polycarbonate crown bridge
Permanent replacement options
- Bridge, denture, implant (need 3 months for bone around XLA socket to stabilise)
- Do not mention unrealistic interventions (assess by case)
Ask if they have any questions- are you happy with what we’ve discussed? Do you have any questions?
Ensure the patient has a clear plan of what will happen next and your roles
Offer them a follow-up appointment or phone number for any questions
Complaints (6 mins)
Complaining about colleague and crown that fell off after a week of being placed.
How would you deal with this patient and their complaint?
Take concerns seriously, answer questions as able:
* ‘Hello there, what seems to be the problem?’
* ‘Can I offer some assistance?’
Acknowledge anger:
* ‘I can see that you’re upset and I am sorry that you feel this way’
* This does not accept blame
* DO NOT ACCEPT BLAME
Try to offer practical help:
* Offer to take over the treatment from your colleague
* Offer investigation with colleague and provide feedback to the patient
* ‘Would you like me to recement the crown?’
* ‘What would you like to do, we can work around you?’
Making an apology:
* Be honest
* Acknowledge the offence
* Explain how it happened
* Ensure amends- ‘is there anything we can do?’
If formal complaint requested, advise on NHS complaints procedure:
* Then, if required, a local resolution (payout)
* If satisfactory- complaint closed
* If unsatisfactory- healthcare commission or health service ombudsman
The NHS complaints procedure:
* Acknowledge the complaint and provide the patient with the practice complaint procedure
* Inform the dental defence organisation if you require advice
* Inform the patient of timescales and stages involved
* Acknowledge the complaint in writing by email or by telephone as soon as you receive it- 3 working days maximum, but ideally within 24 hours
* Early resolution 5 working days for issues that are straightforward and easily resolved, requiring little or no investigation
* Investigation 20 working days for issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’
* Independent external review ombudsman for issues that have not been resolved
What is the ARR (Absolute risk reduction) mean?
What does it mean if the ARR is 0?
The difference in risk between the groups
0 = value of no difference
Therefore If the confidence interval range overlaps 0 = null hypothesis
I.e., if the risk reduction with intervention was 0 then the intervention is the same as the control
What is the RR (The ratio of the risk in each group)
How is the RR calculated?
What does it mean if the RR is 1
Calculated- risk in intervention group / risk in control group
The relative risk (also known as risk ratio [RR]) is the ratio of risk of an event in one group (e.g., exposed group) versus the risk of the event in the other group (e.g., nonexposed group).
1 = value of no difference
Therefore If the confidence interval range overlaps 1 = null hypothesis
I.e., if the ratio with intervention risk over the control risk was 1 then the intervention and control risk are the same
With a CI (confidence interval) of 95 what does that mean? and what happens if the CI overlaps 0.
With a 95 percent confidence interval, you have a 5 percent chance of being wrong.
If CI overlaps 0- indicates that there is insufficient evidence for a difference between the treatment and control group in the population
