Paper 3: PTSR, PHEBD Flashcards
What are health determinants?
The many factors which shape and determine individual’s health
Complex interaction b/w individual characteristics, lifestyle and physical, social and economic environment
Economic hardship correlated w/ poor health
Inc. education strong and significant correlation improved health
Define health inequalities
Differences in health status or the distribution of health determinants b/w different popn. groups
Preventable and unjust differences experienced by certain groups
- low SES > chronic ill-health, die earlier cf high SES
Discuss inequalities in health determinants
SE, cultural, environmental
- education, employment, living and working conditions
- overcrowding, access, language and cultural barrier
Social and community networks
- social cohesion, isolation
Lifestyle
- smoking, alcohol consumption
- diet, physical activity
Social determinants of health
Poverty Social exclusion Discrimination Poor housing Unhealthy early childhood conditions Low occupational status
Discuss social gradient in health and clustering of behaviours
Inequalities in health status are related to inequalities in social status
- life expectancy, chronic disease (CVD, DM, cancer)
Poorest have worst health
- health behaviours are socially patterned as social gradient within behaviours
- global phenomenon; affects everyone
Clustering
- evidence of clustering of health behaviours and co-distribution
- multiple risk factors are more common in some groups
- more likely have poor health outcome
Discuss the life course approach of health inequalities
Biological, behavioural and social factors throughout life cumulatively impact health in adult hood
Environmental exposures may impact on development of chronic disease in later life by programming structure/function of organs/body systems
Factors affecting the life course approach
Accumulation of risk overtime
Chain risk model: sequence linked exposures raise risk
- 1 bad experience/exposure tends to lead to another
Critical periods: exposure during critical period of development
- potentially effect structure/function of organs/tissues/systems not modified in later life
Susceptibility
Time
Vulnerability
Discuss causes and importance of oral health inequalities
Causes
- main causes are social determinants (causes of causes)
- common risk factors for many chronic diseases (DM, CVD, mental illness, cancer)
— poverty, deprivation, employment, education
— diet, smoking, alcohol consumption
— injury
— hygiene
Importance - quality of life; ability to eat, speak, socialise, sleep, smile - psychological and social impact - costly to treat — Sweden 8% of health budget, UK 3.5% - preventable
What is the common risk factor approach?
Method to tackle and prevent health inequalities by targeting shared risk factors of diseases
Non-communicable diseases (CVD, CRD, DM, cancer) biggest killers and have shared risk factors (tobacco, diet, inactivity, alcohol )
- prevent by tackling these risk factors; most effective
6 key areas for tackling health inequalities
Give every child best start in life
Enable everyone to max. capabilities and control their lives
Create fair employment and good work for all
Ensure healthy standard of living for all
Create and develop healthy and sustainable places and communities
Strengthen role and impact of ill health prevention
Define health promotion
Process of enabling individuals and communities to inc. control over health determinants thus improve their health
How has health promotion worked so far and how should this change?
Focused on downstream actions w/ limited effect
To be successful in changing behaviours need to change environments to ensure healthier choices are easier choices
5 action areas for health promotion outlined by Ottawa charter
- Building healthier public policies
- Creating supportive environments
- Strengthening community action
- Developing personal skills
- Reorientating health services towards prevention
5 approaches to health promotion
- Social change
- recognises importance of SE and environmental factors in determining health - Empowerment
- support individuals in identifying concerns, priorities and developing skills to make change - Preventive: clinicians deliver preventive advice/Tx
- Social change
- encourage changing unhealthy behaviours to healthy ones
- assumes if given knowledge will change behaviour - Education
- knowledge alone is insufficient to make change
- need to develop skills and attitudes
Discuss up, mid and downstream approaches to health promotion
Upstream: legislative and fiscal policies
- Ottawa: building healthy public policy + creating supportive environments
- sugar tax, guidelines on sugar consumption
- smoking ban in public places
- free pre-school places to support parents and promote child development
Midstream: Training wider workforce on oral health
- Ottawa: strengthening community action + developing personal skills
- training community health champions
— deliver oral health advice, signpost community dental services
- healthy food policies in nurseries and schools
Downstream: 1ry care approaches
- Ottawa: re-orientating health services towards prevention
- implementation of prevention @ chair side using CRFA
- DBOH: prevention toolkit
Discuss building healthier public policy and give examples
Mainly: legislation, fiscal measures, taxation organisational change
Subsidies for health related products - staple foods to red. malnutrition and improve nutrition Tax and Tax Expenditures - incl. excise and VAT; sugar, tobacco, alcohol - exemption from taxes Reducing availability - ban in schools - limit no. on high street/area
Discuss creating supportive environments, give examples
Socio-ecological approach; safe, stimulating, satisfying, enjoyable living and working conditions
Healthy Cities
- address inequality in health and urban poverty
- needs of vulnerable groups
- governance
- social, economic, environmental health determinants
Congestion and Pollution: London congestion charge
Health Promoting Schools; Sugar Smart (Jamie Oliver)
Discuss Health Promoting Schools
Environment: physical, cultural, policies
- safe, well-designed buildings and playgrounds prevent injury
- no smoking, healthy foods served, packed lunch checks
- safe water and good sanitation
- protocol for bullying and violent behaviour and interpersonal conflict
Practice: curriculum, teaching, learning
- curriculum change; health education part of every subject
- training staff
Partnership: students, families, community, business
- work w/ central/local health service providers
- support school/community-based health promotion actives (breakfast club)
Discuss strengthening community action
Empowerment of communities to achieve social and political changes to improve their own health and control destinies
Mobilising Community Assets: knowledge, skills, physical and social resource
Community Capacity Building
- inc. resources and attributes through inc. knowledge, skills and competencies
Peer Support and Volunteers
- trained volunteers to enhance knowledge and skills to promote health
- Health Champions: provide and signpost health services
- Breastfeeding cafe
Partnerships: local health and social care services
Improving access: obvious resource centre to provide help and advice
Discuss developing personal skills
Provide individuals w/ health education and enhancing life skills to make choices conductive to health
Setting: school, home, work, community as individuals/communities/popn.
Empowering individual/community to take control over health through building confidence and self-esteem
Inc. knowledge, awareness, skills to promote +ve health change
Improving health status by supporting and giving skills to manage long term chronic conditions
Delivering Better Oral Health
Discuss reorientation of health services; how it can be achieved and an example
Health services must be sensitive to and respect cultural needs
How
- organisational change supports health promotion environment and capacity building of health service staff
- engagement and training of staff to practice evidence based medicine and promote health
- partnership and collaboration w/ communities and organisations
— priorities of community are priorities of health service
Primary Health Care Approach Principles - equity in access to care - prevention and promotion - community participation - multi-sectorial approach - appropriate technology
Goals
- red. exclusion and social inequalities in health
- organising health services around needs and expectations
- integrating health into all sectors
- pursuing collaborative models of policy dialogue
- inc. stakeholder participation
Compare health, disease and illness
Health: complete state of physical, mental, social well-being not merely absence of disease
Disease: named pathological entities diagnosed by clinical signs and symptoms
Illness: how person feels when unwell and effect on their normal everyday life
Define oral health
WHO
Being free from: facial + mouth pain; oral + throat cancer; infection + sores; PD disease; tooth decay/loss; and other diseases that limit capacity to chew/smile/speak/bite and psychological well-being
Types of need and how these are measured
Normative
- defined by professionals using agreed criteria
- exam, BPE, X-ray, index of orthodontic Tx need
Felt
- what individual perceived as important to them
- history taking
Expressed
- arise when felt need turned into action
- dental attendance
Comparative
- comparing needs on one individual/group to antiheroes
- variations in attendance by gender, age, region
How do we assess impact on disease on QoL?
Oral Health Impact Profile (OHIP)
- questionnaire
- 7 domains
- condensed format has 2Qs/domain
- rate: hardly ever, occasionally, fairly often, very often
Domains of the OHIP-14
Functional Limitation
- speak properly
- sense of taste
Physical Pain
- painful aching
- pain whilst eating
Psychological Discomfort
- worried
- tense
- self-conscious
Physical Disability
- unable to eat satisfactory diet
- interrupt meals
Physiological Disability
- embarrassed by teeth
- unable to relax
Social Disability
- unable to do normal jobs
- irritable w/ others
Handicap
- feel life in general unsatisfactory
- unable to function
Define special care dentistry
GDC 2008
Improvement of OH of individuals/groups in society who have physical, sensory, intellectual, medical, emotional or social impairment or disability or, more often, a combination of these
Define impairment, disability and handicap
Impairment: any loss or abnormality of psychological, physiological or anatomical structure or function
Disability: any restriction or lack of ability to perform activity in manner or within range considered normal
Handicap: when an individual w/ impairment can’t fulfil normal life role
Do all pt w/ disability req. SCD? What is the hierarchy for this?
No; most seen in GDP
If can’t be seen in 1ry care -> CDS -> hospital
Tier 1: seen by anyone w/ no specialist skills
Tier 2: additional complexity; hoist into dental chair
Tier 3: multi-disciplinary care; specialist or consultant
Main Tx modalities for SCD
LA
Sedation: IV or inhalation
GA: do need pre-medication/sedative?
Discuss Equality Act 2010 and impact for dental practice
Illegal to discriminate anyone w/ any form of disability
HCP must make reasonable adjustments to facilitate that attendance of individuals w/ disabilities to practice
- hoists
- ramp
- handrails
4 key areas req. consideration when Tx special care pt
Access - to dental service - to chair - to mouth Valid consent Education: educate pt/carers on OH Safety: pt, self, staff - challenging behaviours
Discuss access to dental service for SCD
Awareness: do pt/carer know service exists
Support: req. transport getting to service?
Preparation: send pics to carers before, anything you can do to help?
Physical barriers: lifts, ramps
Info. provision
Extended services
Discuss how we can aid access to dental chair
Turntable: pt swivel into chair Hoist: attach pt to, move into chair Diaco chair: wheelchair recliner - more comfortable for pt - better access Bariatric chair: obese pt, support 180kg+
Discuss how to aid access to mouth in SCD
Physical support: hold pt if trained
Clinical holding
Positioning: often not ideal
Equipment design
Acclimatisation: good for Autism
- get pt outside, then into waiting room, then into surgery -> chair
Pharmacological management: sedation ease visit
What is valid consent?
Consent given freely
With all relevant information
Information is understood
Pt has capacity
Discuss the 5 key principles of the Mental Health Capacity Act 2005
Capacity presumed unless proven otherwise
Support pt decision making: communication aids
Respect right to unwise decision
Req. to act in pt best interest
Requisite to consider least restrictive option
How do we assess capacity?
2 stage test
Does pt have impairment/disturbance of mind/brain?
Is impairment sufficient that they lack capacity to make decision?
What are the criteria for someone to have capacity?
Must
- understand info
- retain info
- weight up info
- communication decision
What do we do if pt lacks capacity?
Tx in best interest: always get 2nd opinion, involve family
Consider Advanced Directives - had capacity + knew was going to lose - dementia, Huntington’s Lasting Power of Attorney - appoint someone to make decision on your behalf - health, welfare or both Court Appointed Deputy Independent Medical Capacity Advocate - no family or friends - involve to help make decision
What are possible communication differences/difficulties for SCD pt?
Anxiety: makes communication more difficult
Sensory: hearing, visual
Neurological deficit: following stroke
- Brocker’s aphasia: understand but lack vocabulary
- Verner’s: articulate but don’t understand
Muscular deficit
- articulation and phonation
- Multiple sclerosis: understand, voice muscles don’t work
Define challenging behaviours
Culturally abnormal behaviour of such intensity/freq./duration that physical safety of person or others is placed in serious jeopardy or seriously limits/denies access to community facilities
Define GA
Drug induced state of reversible, controlled unconsciousness during which pt not rousable
Indications for GA
General
- anxious pt w/ OSA
- multiple XLA/8s
- failed sedation
- maxfax
SC
- aspiration risk: instruments, saliva
— cerebral palsy: infection + pneumonia post surgery
- cognitive impairment w/ challenging behaviours
- multi-disciplinary care
Contraindications for GA
Allergy to drug
Social: no escort for sedation
Advanced cardio-respiratory disease
Factors important in medical and social history for GA
M
- CV or respiratory disease
- habitus
- veins
S: does pt have support from friends/family/carers
Importance of previous GA and airway history for new GA
GA
- suxamethonium apnoea (lack enzyme to metabolise)
- malignant hyperthermia
- adverse reaction/allergy
Airway
- failed intubation
- unstable cervical spine
- specific syndrome: Treacher Collins
- limited opening
- acromegaly
- ankylosing spondylitis
- rheumatoid arthritis
Medical and dental considerations when considering pt for GA
M
- liaise w/ anaesthetist, gastroenterologist, ENT
- investigations: blood tests, ECG, echo
D
- CONSENT: pt best interest
- realistic Tx planning: not having multiple GA
- reasonable adjustments (facilitating access to care)
— multiple specialities working in 1 appt
Discuss aspects of intra-operative care during GA
Maintenance: sevoflurance, propofol Analgesia: fentanyl, local analgesia Anti-emetic: cyclizine, ondansetron Fluids: saline Pt warming (prevent hypothermia) Venous thrombosis prophylaxis: enoxaparin - stocking, calf compressors Steroids
In the recovery of GA what is special consideration for SCD pt?
Reasonable adjustment as soon as ready let them go as may be traumatising keeping them longer than req.
Risks + side effects of GA
Nausea, vomiting Sore throat/nose Shivering Trauma to dentition - tooth dislodged by oropharyngeal scope - check before + after Corneal abrasions Chest infection Delirium/cognitive dysfunction Anaphylaxis: 1:15000 Awareness: 1:15000 Nerve damage Death: 1:100000
Important blood tests to check for medically compromised pt
Hb: 13-17g/dL - GA/sedation: <8x10^9/L Neutrophil: 2-7x10^9/L - low = infection susceptibility Platelets: 150-400x10^9/L - low = bleeding - infiltration: 20 - IDNB: 30 - XLA: 50 - surgical: 75 INR: 0.9-1.1 - higher = bleeding
Discuss the implications of weight for Tx SCD pt
Overweight - airway management + handling issues - bariatric chair? - co-morbidities — CVD — DM — fatty liver disease
Underweight
- anaemia
- bradycardia, hypotension
- psychiatric: diabulimia
- osteoporosis
- reflux
- dental implications: erosion
Discuss respiratory disease considerations for SCD
Asthma - how well controlled? - poorly: extra care — have been hospitalised? — how many steps before difficulty breathing? - Rx condition on Tx day - bring inhalers w/
COPD: emphysema, bronchitis
- most undiagnosed airway condition
- productive cough + U airway sensitivity
- low baseline O2 saturation; esp. smokers
Discuss medications used to Tx COPD
Pt using medication further down indicates poorly controlled at some point
Salbutamol (short acting B2 agonist)
Beclometasone (glucocorticoid)
Salmeterol (long acting B2 agonist)
Theophylline
Compare T1 and T2 DM
T1: IDDM
- younger popn.
- lack insulin thus pt on insulin
- more difficult to control
T2: IIDM
- older
- Afro-Caribbean
- insulin resistance (rarely on insulin)
Common complications of poorly controlled DM
Eyes: retinopathy, leading cause of blindness
Heart: atherosclerosis -> TIA, MI, angina
Kidney: nephropathy -> chronic kidney disease
Feet: infections, paraesthesia (polyneuropathy)
Discuss medications used for Tx of DM
T1: insulin
T2
- metformin
- + sulphonyurea (gliclazide) or DPP-4 inhibitor (sitagliptin)
- + thiazolidinediones: pioglitazone
- + insulin = poorly controlled @ some point
What is glycated Hb? How is it used?
Hb1Ac: measure of glycosylated Hb in blood over 3/12
Low = well controlled
<42mmol/mol = normal
42-47: prediabetes
>48: diabetes
Discuss cardiac risk groups and implication for AB cover
Groups
- cardiomyopathies
- valve disease w/ stenosis/regurgitation
- valve replacement
- congenital HD
- previous Hx IE
Cover
- NICE: no one needs cover
- previous IE: cultures isolated? Oral bacteria?
- consult cardiologist
Discuss anticoagulant medications and implications for dental Tx
Warfarin
- VitK dependent CFs: 2, 7, 9, 10
- INR<4 for Tx/XLA
LMWH: enoxaparin, dalteparin, tinzaparin
- CF2, 10
- kidney pt on dialysis
NOACs - dabigatran: thrombin inhibitor — skip morning dose - apixaban: CF10A inhibitor — skip morning dose - rivaroxaban: CF10A — 1/day — delay morning dose until 4h post-haemostasis
Signs of pt w/ bleeding disorder
Bleeding gums Previous bleeding post-op Easy bruising Haemaethrosis: bleeding into joints Petechiae: skin bleeding Heavy periods
Signs of renal failure/disease
Lemon tinge to skin Halitosis Peritonitis Hypertension Anaemia: EPO (hormone) prod. RBC Bone pain: VitD, Ca2+ regulation Proteinurea Itchy skin
Dental Tx implication for renal pt
Access
- if on haemodialysis must see day after dialysis
- given heparin + will be lethargic
Risk assess chance of bleeding
Signs of liver disease
Encephalopathy Bleeding: CD 2/7/9/10 Jaundice: bilirubin Dry mouth/excessive thirst Gynecomastia Infections: dec. macrophages Ascites Telangiectasia Dupuytren’s Contracture Hepatocellular carcinoma Resting tremor
Implications of liver disease on dental Tx
Poor OH: Dupuytren’s contracture, resting tenor, encephalopathy
Caries: above + dry mouth
Infections
Bleeding
Do clotting screen pre-Tx
Common immunosuppressant drugs
Tacrolimus: interaction w/ erythromycin Cyclosporin: gingival swelling Mycophenolate mofetil Prednisolone: how long? Monoclonal Abs: fewer side effects
Dental impact of pt on immunosuppressants/transplant
No Tx for 1st 3/12: rejection likely Prevention is key Review regularly Infections - Candida - HSV - oral hairy leukoplakia - ulcers
No AB cover
Steroid cover if req.
What is graft v host disease? Dental relevance?
Immune condition where graft immune cells attack host tissue
Dental: most likely to be 1st clinician to see
- ulcers
- hyperkeratotic patches
- mucosal atrophy
- lichenoid changes
- erythema
Pre-Tx checks for HIV pt
How long have had HIV? What medications on? - atripla - combivir - kaletra Bloods - CD4 >200: immune response - VL <40: infectivity - platelets: inc. likelihood thrombocytopenia (low)
Discuss psychiatric disorders and dental relevance
Under-diagnosed + inc. (esp. young) May not disclose Clues: MH + drugs - typical: clozapine, haloperidol - atypical — olanzaline — risperidone — amisulpride — ariprazole - side effects: pancytopenia (red. WBC, WBC, platelets)
Dental
- anxiety
- eating disorder: erosion
- dementia
- bleeding, infections
Dental management for thalassaemia and sickle cell disease pt
Inhalation sedation generally safe - care w/ GA Avoid - hypoxia: O2 for 5 mins pre-appt - hypothermia: give blanket - hypovolaemia: ensure drink plenty water Red. dental related stress Tx infections aggressively - post-op ABs for all surgeries Avoid high dose aspirin
General signs and symptoms of oncology pt
Malaise Fever Lymphadenopathy Bleeding gums Weight loss Haematurea Infections VTE/PE
Importance of chemo and radiotherapy for oncology pt and dental relevance
Tx modality
Chemotherapy - leads to pancytopenia — low neutrophils -> infections — low platelets -> bleeding — low RBC -> anaemia
Radiotherapy
- osteoradionecrosis
- must know RT fields + sites
- dose?
Dental impact of chemo-radiotherapy
Mucositis: inflammation and ulceration of mucosa Loss of taste Dry mouth: immediate and long term Caries Trismus
What is osteonecrosis? Aetiology and pathophysiology
Exposed bone for >2/12 (in irradiated site for ORN)
Aetiology
- trauma: XLA, biopsy, ill fitting denture
- spontaneous: mylohyoid ridge
Pathophysiology
- endarteritis (inflammation of artery)
— dec. vascularity, abnormal fibroblast activity, red. osteocytes
— = red. bone turnover
Signs of ONJ
Erythema Swelling Discharge Pain Exposed bone Oro-cutaenous fistula Pathological #
Issues w/ caring for older pt
MH - safety - ability to accept Tx - prioritisation Attitude towards Tx
Dental and mucosal changes seen w/ ageing
Dental
- calcification
- inc. mineralisation
- wear
Mucosa
- red. mucosal thickness
- loss of vascularity
- red. cell turnover
Pathological changes seen in OH w/ ageing
Red. saliva flow: normal physiological + poly-pharmacy
Alveolar bone restoration
- following XLA/loss
- physiologically accelerated in some pt
- WHO: severely red. ridge = disability
Loss of muscle tone + strength
- red. bite force
- mobility issues
- access: chair transfer
Discuss chronic dental disease and older pt ability to self care impact on OH
Chronic disease
- progressive PDL loss (mobility, loss)
- extensive, complex restorations
Self Care - frailty: stroke, Parkinson’s, arthritis — unable to brush - dementia: completely dependent - depression, social isolation
Link b/w OH and medical health esp. in older pt
Aspiration pneumonia
- poor OH + PD disease contribute
- plaque acts as bacterial reservoir
- hospital/care home pt have poor OH + 48% of infections care home pt
DM
- well established risk for PD disease
- PD inflammation associated w/ impaired glucose tolerance
CVD + Stroke
- some evidence of PD disease link
- PD disease may be risk factor for CVD
What habits do older pt tend to have which impact oral health?
Sugar: inc. amount + freq.
OH: less brushing 2x daily
3 main methods of prevention for older pt
Fluoride
Plaque control/OH
Diet modification
Discuss provision of F for older pt
High conc. toothpaste (Duraphat): 2800/5000ppm Use weekly rinse (0.2%) daily - only if will spit H2O fluoridation FV: every 3/12, 22600ppm
Issues w/ + methods of plaque control for older pt
Dexterity problems
- modified brush: putty to shape handle
- electric brush
- chlorhexidine: adjunct
Dependency: training of carers (effect short lived likely due to turnover of carers)
HCP: regular hygiene appt
Interdental aids
Signs of learning disability
Speech impairment
- verbal limitation
- use alternatives: sign language, written
Poor OH
- severe LD hate having things in mouth
IQ
- profound <20
- severe <35
- mod 35-49
- mild 50-69
Mortality 28x higher
LE 4x lower
Types, Dx and Tx for Down’s syndrome
Types
- trisomy 21 93%
- translocation trisomy 21
- mosaicism
Dx: USS; width of head
Tx: SALT, physio
Facial features of Down’s syndrome
Mongoloid appearance
Brachycephaly
Mid-face hyperplasia
Denture features of Down’s syndrome
Microdontia Hypodontia Macroglossia Malocclusion Fissured tongue PD disease + caries
Signs of Down’s syndrome
Learning difficulty: 100% pt Dementia: 55% Leukaemia: 10-20x higher Brushfield’s spots/cataracts Clinodactyly Simean crease Short neck Atlanto-axial instability Joint flexibility ASD/VSD: 53% Hypothyroidism: 27% -> weight gain + obesity Short stature Hearing impairment
Discuss autism
Aetiology unknown: possibly chromosome 15
Spectrum of disorders
Triad of impairments - social communication - social imagination - social isolation Possibly accompanied by challenging behaviour Desire for sameness/routine
Signs of autism
Hate eye contact Learning disability Challenging behaviour: possible GA Self harm Fixation w/ numbers Repetitive movements Mood disorder Dislike physical stimuli
Aetiology of cerebral palsy
Prenatal
- maternal infection: acute (rubella), chronic (syphilis, herpes)
- maternal dysfunction: DM, hypertension
- drugs: alcohol, recreational
Neonatal
- prematurity
- difficult/prolonged labour
- hypoxia (most common)
- birth injury
Postnatal
- trauma, brain tumour
- infection: meningitis, encephalitis
- toxins: Pb, hydrocarbons
Types of cerebral palsy
Spastic (50-60%): cortical motor area
- exaggerated movements, inc. muscle tone, hyperreflexia
- inc. spasticity, contracture
Athetoid (20-35%): basal ganglia
- writhing, wormlike movements
Ataxic (7-15%): cerebellum
- lack coordination (hand to eye), balance problems (gait)
Signs of cerebral palsy
Epilepsy (30%)
Learning disability
Sensory impairment: hearing, visual, speech
Uncontrolled movements
Oral features of cerebral palsy
Malocclusion: class 2 div 1 (lack muscle tone) High palatal vaults Tongue thrust, mouth breathing Drooling - Botox injection + anticholinergic patches -> xerostomia Xerostomia: caries Narrow arch Enamel hypoplasia Bruxism
PD disease 3x higher
What is Parkinson’s disease?
Motor neurone disease caused by degeneration of dopaminergic cells in substantia nigra
Aetiology of Parkinson’s
Multifactorial
Genetics
Idiopathic
Drug: neuroleptics (reserpine, phenothiazines)
Post-viral encephalitis, other degenerative
Diffuse brain disease causing generalised cerebral damage: Alzheimer’s
Tx of Parkinson’s
Physio +
Levodopa
- dopamine precursor; replenish dopamine
Adverse: hallucinations, confusion, dystonia, xerostomia
Use w/ dopa decarboxylase inhibitor to allow lower dose w/ inc. dopamine conc. centrally
Signs of Parkinson’s
Mask-like face
Facial rigidity
Red. spontaneous blinking
Speech slurring
Bradykinesia: slow movements + hesitant initiation
Dyskinesia: involuntary movement
Pill-rolling Tremor
Limb rigidity
Shuffling gait
Dental implications of Parkinson’s
Accommodation: on + off days/times
Give pt time for communication
Disease: xerostomia, dietary supplements (high sugar), red. dexterity
What is multiple sclerosis? Aetiology?
Neurodegenerative disease caused by damage to myelin sheath of brain + spinal cord
Aetiology: unknown
Types of multiple sclerosis
Benign (20%): few mild attacks then complete recovery
Relapsing/Remitting (25%): symptomatic + asymptomatic periods -> 15y
2ry progressive (40%): begin as R/R, symptoms more freq. + worse
1ry progressive (15%): early onset, worsen over T w/ period of remission
Signs of multiple sclerosis
Fatigue
Sensory impairment: visual, verbal (articulation)
Breathing: shortness of breath, coughing, difficulty
Uncontrolled movements + spasticity
Oral features of multiple sclerosis
Xerostomia
Caries
Tx of multiple sclerosis
Disease modifying drugs: red. no. relapses + slow progression
No Tx for 1ry progressive
Physio + steroids to speed recovery b/w attacks
Drugs: anti-incontinence, cannabis (pain)
Dental implications and management for pt w/ multiple sclerosis
Implications
- cannabis -> caries (munchies)
- dry mouth
- trigeminal neuralgia: don’t know cause of pain as communication difficult
Tx
- consent: pt understands!! Find way to communicate
- aspiration risk later stages: RD
- prevention
Aetiology of Huntington’s disease
Neurodegenerative
Autosomal dominant
Faulty gene on chromosome 4
- causes cerebral atrophy + mutated huntingtin protein
Signs of Huntington’s disease
Speech impairment Uncoordinated, jerky movements Lack of coordination Unsteady fair Suicide risk Dementia Mood + cognition changes swallowing difficulty p
What is a stroke? Risk factors
Sudden neurological deficit, vascular in origin lasting >24h Risk factors - DM, obesity - smoking - hyperlipidaemia - heart failure - carotid artery stenosis - ischaemic heart disease - Afib
Differentiate b/w 2 types of stroke
Haemorrhagic: weak/diseased blood vessel ruptures, blood leaks into brain
Ischaemic: blood clot prevents blood flowing to brain
Tx of stroke
Initial
- thrombolysis: only ischaemic
- surgery: stent, hemicraniectomy
Prevention: anticoagulation (ischaemic)
Rehab: SALT, OT, physio
Complications of stroke
Paralysis, muscle weakness
Incontinence
Social isolation
Dementia
Dysphasia
Agnosia: inability to process sensory info
Dyspraxia: poor coordination
Dysarthria: poor articulation (slurred)
Aphasia (difficulty understanding)/Dysphasia (difficulty generating)
Loss of language
Dental features and implications for Tx for stroke pt
Features
- xerostomia
- caries: B/root
- facial paralysis
- PD disease
Tx
- access: wheelchair recliner, hoist
— domiciliary care, pt transport
— poor attendance
- position + handling: leaning to 1 side; cushion/support
- aspiration risk
- OH: toothbrush/denture modifications aid cleaning
- dentures: help put in, adjust to accommodate loss of muscle
What is dementia? Aetiology
Progressive and irreversible impairment of cognitive function
Alzheimer’s most common
Aetiology
- unknown
- no. of possible causes, nothing conclusive
Signs of dementia
Memory loss - initially short term, then long term Orientation: where they are, movements Understanding: language, confusion Language: lack Personality + behavioural changes
Management of dementia
No cure, maintain QoL
Drugs
- slow progression
- manage associated behaviour/depression
Impact of dementia on dental care + Tx
Care
- cooperation: confusion, aggression, forgetfulness
- OH: dependent on others, train carers
- consent: check continually as progresses -> best interests
Tx Early - major Tx - clear + simple communication - LA + TLC - clinical holding Moderate - Least traumatic, similar surroundings - IVS/GA if medically stable + cooperative — slow, careful administration Advanced - as above + — palliative care — pain management
Aetiology of anxiety + possible reasons for dental anxiety
Aetiology
- last threats
- lack of control
- previous learning
- classical conditioning
- cultural: films/torture
Dental
- hierarchy of dental Tx related-anxiety: XLA > LA > filling
- anticipation
- triggers
— visual: instruments
— auditory: sound of drill
— olfactory: smell of practice/medicaments
Behavioural and physiological signs of anxiety
Behavioural
- verbal abuse
- excessive talking (delay)
- cancelling/late/missing appts
Physiological
- pallor, sweating
- dry mouth
- knotted stomach
- flushed face
- extreme muscle tension
- fainting, hyperventilation
- inc. HR + BP
Discuss the modified dental anxiety scale
Measurement of severity of anxiety
5Qs, 5 responses
Score = sum of responses
- 19+ = high anxiety
Quick, easy
Management options for pt w/ anxiety
Behaviour techniques + psychological methods
Pharmacological
- GA
- conscious sedation: IVS, IHS, oral
Discuss midazolam: t1/2, pharmacodynamics
Distribution t1/2: 6-15min Elimination t1/2: 1-3h - ~8-12h before cleared Relatively inactive metabolites High therapeutic index: wide margin of safety
Pharmacodynamics
- anxiolysis
- muscle relaxant
- anterograde amnesia
- sedation
Midazolam mechanism of action
Benzodiazepine receptor agonist
BZD R associated w/ GABAA R
Midazolam inc. effect GABA on GABAA R causing influx of Cl- resulting in cell inhibition
Discuss flumazenil
Competitive antagonist @ BZD R (prevent midazolam binding)
Used as BZD antidote
- reverses all effects of midazolam except anterograde amnesia
Elimination t1/2: 1-1.5h (shorter)
- during this re-sedation won’t occur
Discuss anterograde amnesia effect of midazolam
Benefit: red. pt’s memory of Tx
Unhelpful
- difficult to wean pt away from sedation Tx
-misinterpreted by pt: ‘put to sleep’
Most profound effect
- immediately after induction
- variable loss of short term memory: hrs-next day
Discuss muscle relaxant effect of midazolam
Generally unhelpful except mouth opening
Difficulty
- standing
- walking
- maintaining balance
Airway obstruction in over-sedated + pt w/ snoring/OSA
- obliteration of oropharynx by tongue falling back
Loss of protected gag reflex
Helpful for pt w/ gag reflex
Discuss respiratory depression effect of midazolam
Usually mild
Mechanisms
- respiratory muscles relax causing dose-related red. rate + depth of breathing
- red. sensitivity of central CO2, O2 chemoreceptors
— red. ability respiratory centre to inc. respiratory drive in presence of high CO2/low O2
Monitoring w/ pulse oximeter mandatory
CV effects of midazolam
Few significant effects
Dec.
- mean arterial pressure
- cardiac output
- stroke vol.
- systemic vascular resistance
Present as small fall in arterial BP
Indications for IHS
Children Mild/mod. anxiety Needle phobia Other sedation C/I Medical condition Long cases (no sedation window)
Properties of NOx + mechanism
Odourless, colourless, nonirritant gas
Low blood solubility
Easy titration
Rapid recovery
Mechanism: unknown
- diffuses into blood, conc. in tissues w/ high blood flow
Systemic effects of NOx
CVS: vasodilation
Resp.: red. rate + depth
GI/liver/kidney: N/A
Haematopoietic: bone marrow suppression
Normal distribution of pts’ response to sedation
Hyporesponder
- effective @ max dose
- abuse of CNS-mediated drug
Hyperresponder
- effect @ low doses
- red. CNS mediation (older)
Paradoxical effects: young, old
Compare titration regime for health adult, elderly and overweight pt
Healthy adult
- 2mg/30s
- pause: 60-90s
- further: 1mg every 30s
Elderly
- 1mg/30s
- pause 120-240s
- further: 0.5mg every 30s
Overweight
- 2mg/30s
- pause 60-90s
- further: 0.5mg every 30s
Req. for level of conscious sedation
Level so pt
- remains conscious
- retains protective reflexes
- able to understand + respond to verbal command
Describe sedated pt and clinical signs
Sedated pt
- relaxed
- cooperative
- dec. awareness of surroundings
- demonstrate diminished response to stimuli
Clinical
- resp: normal 12-20/min
- eye: follow finger (slower)
- protective reflexes intact
- eyelid reflex: intact (conscious), absent (over-sedated)
Signs of over sedation
Unconsciousness
Irregularly respiratory pattern
Hyperactive reflex
Discuss management of over-sedation
Small amount
- uncooperative (refuse to open mouth)
— delay Tx start
- waiting few mins usually resolves
Gross
- profound respiratory depression or apnoea
- immediately stop Tx, maintain airway, ventilate if req.
- reverse sedation
Discuss titration regime for flumazenil reversal of sedation
Initial dose: 0.2mg/15s
Further: 0.1mg every 60s; max 1mg
Usually 0.3-0.6mg
