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BDS4 Special Care Dentistry > Physical & Learning Disabilities > Flashcards

Physical & Learning Disabilities Flashcards

1
Q

What does the bio psychosocial model detail?

A
  • general acceptance that illness and health are the result of an interaction between biological, psychological and social factors
  • patient centred care
  • collaboration and sharing of care and resource
  • successful and sustainable health system
  • social determinants of health
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2
Q

What barriers exist to accessing care?

A
  • individuals and groups
  • population
  • oral health
  • prevention at primary, secondary and tertiary levels
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3
Q

What active barriers exist for older people accessing dental care?

A
  • cost
    • fear of cost
  • fear
    • dental anxiety
  • accessibility
  • availability
    • NHS vs. private
  • characteristics of dentist
    • personality
    • politeness
    • professionalism
    • perception of service
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4
Q

What financial barriers exist for patients?

A
  • direct
    • cost of treatment
  • indirect
    • travel
    • carers
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5
Q

What protected characteristics exist for older people accessing dental care?

A
  • perceived difficulty in finding a dentist
    • complicated by lack of awareness of dental pathways
  • cost of treatment
    • accessing information
  • difficulties finding suitable transport
    • availability of escort
  • organisational barriers
    • lack of availability of dentists offering domiciliary care
  • dental practitioners find domiciliary care challenging
    • lack of experience in palliative dental care
  • patient management skills for geriatric patients
    • found to be inadequate
  • physical barriers
    • reduced mobility
  • lack of flexible opening times
    • difficult to arrange an escort
  • barriers related to paid carers
    • lacking knowledge of patient’s medical history
    • payment process
  • lack of motivation or interest in oral health training
    • care home staff
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6
Q

What protected characteristics exist for patients with disabilities?

A
  • inability to tolerate treatment
  • lack of knowledge of access to oral healthcare services
    • lack of social support
  • difficulty finding a dentist that will provide treatment
    • lack of education and training
  • communication barriers
  • domiciliary care
  • information in appropriate formats
  • oral health knowledge and expectations of carers
  • physical barriers
    • transport
    • waiting areas
    • toilet facilities
  • collaboration between services
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7
Q

What barriers exist to accessing adjacent therapies?

A
  • sedation
    • limited in general dental services
      • ASAI and ASAII in primary care
      • ASAIII and ASAIV in hospital setting
    • case complexity
    • techniques available
  • general anaesthesia
    • varies by region
    • number of lists
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8
Q

What barriers exist for medically complex patients to access dental care?

A
  • individual level barriers
    • may not tolerate some procedures
    • may find oral hygiene difficult
  • organisation level barriers
    • administrative difficulty to manage care
    • number of patients exceeds capacity
    • health professionals unaware of dental consequences of medical treatment
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9
Q

What barriers exist for patients struggling with mental health conditions trying to access dental care?

A
  • individual level barriers
    • feelings of shame, guilt, stigma, low self-esteem and helplessness
    • confusion and lack of recall of converations
    • public services perceived as inadequate
  • organisational level barriers
    • lack of protocols
    • lack of staff time
    • general dentists reluctant to treat
    • limited specialised expertise in managing individuals with high treatment needs
    • discrimination regarding the use of limited resources
  • policy level barriers
    • service organisation with move from institutional to community living
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10
Q

What barriers exist to patients in the West of Scotland to patients with hereditary bleeding disorders trying to access dental care?

A
  • travel
    • flight
    • overnight stays
  • entry to department
    • ambulance transport
    • parking
    • lift or ground floor access
    • hoist
  • dental treatment
    • specialised unit with medical input
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11
Q

How does the distribution of general dental practices act as a barrier to some patient accessing dental care?

A
  • dental practices not socioeconomically distributed
  • remote areas have less access
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12
Q

How can oral health literacy act as a barrier to dental care?

A

-individual capacity to understand and use dental information to transform oral health behaviours

  • low oral health literacy limits the capacity to understand dentist’s instructions which hinders the maintenance of oral health
  • strong evidence linking oral health status and oral health literacy
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13
Q

What is oral health literacy?

A

the degree to which individuals have the capacity to obtain, process and understand basic oral health information and services needed to make appropriate health decisions.

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14
Q

What are the key barriers to effective communication?

A
  • limited time
  • financial incentives promoting treatment over prevention
  • lack of oral hygiene literacy training
  • limited plain-language patient education materials
  • patients with low oral hygiene literacy knowledge
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15
Q

What is the common risk factor approach?

A
  • different risk factors impact multiple systems resulting in shared barriers
  • diet
    • obesity
    • cancers
    • heart disease
    • dental caries
    • periodontal disease
  • stress
    • heart disease
    • periodontal disease
  • smoking
    • cancers
    • heart disease
    • respiratory disease
    • periodontal dusease
  • etc.
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16
Q

What behaviour barriers exist for patients with autism spectrum disorder?

A
  • ability to comply with oral hygiene
  • oral aversion
  • food selectivity
  • altered response to behavioural conditioning
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17
Q

What social and communication skill barriers exist for patients with autism spectrum disorder?

A
  • inhibited social and communication skills
  • communication of pain, concerns and needs
  • ability to understand own health needs
  • lack of cooperation with personal care
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18
Q

How does parental dependance act as a barrier for patients with autism spectrum disorder?

A
  • require support
  • low prioritisation of oral care
  • confidence to engage with professional
  • struggle to ask for additional support
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19
Q

How does the clinical environment act as a barrier for patients with autistic spectrum disorder?

A
  • physical environment not conductive to care
    • visual, auditory and tactile stimuli
  • busy waiting areas
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20
Q

How do oral health professionals act as a barrier for patients with autism spectrum disorder?

A
  • lack of education
  • families refused care
  • individualised care
  • involving people with ASD in their care
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21
Q

What barriers exist to patients with learning disabilities accessing dental care?

A
  • individual-level barriers
    • lack of consent
    • complicated medical histories
    • inability to cooperate with treatment
    • inability to communicate dental pain
  • organisational level
    • general dentists reluctant to treat patients
    • shortage of specially trained dentists
  • policy level
    • service organisation as people with learning disabilities move from institutional to community living
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22
Q

Provide examples of facilitators of oral health

A
  • reported need for education and training
  • financial support
  • dentists’ chairside manner
  • community support
  • interprofessional communiation
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23
Q

How can transitional arrangements act as a barrier to accessing dental care?

A
  • ensuring a defined path of transitional care can prevent deterioration
  • when a person with intellectual disabilities turns 18 they move into adulthood and oral health deteriorates fast
    • paediatric to adult services
    • easy for patients to get lost
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24
Q

Why must clinical special care dentistry be prioritised?

A
  • to reduce inequalities
  • to provide opportunities to learn, gain confidence and collaborate
  • ups killing undergrads means they are more likely to deliver care on graduation
  • confidence and competence enhances patient acceptance
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25
Q

What barriers exist for a user and carer trying to access dental care?

A
  • physical, mental and cognitive ability
    • carrying out effective oral hygiene, diet, decisions and treatment
  • ability to self-care
  • diet
    • high calorie food
  • dry mouth
  • sugar based medications
    • laxatives
  • communication
  • fear and anxiety
    • irregular attendance
  • behavioural management
    • sedation
    • general anaesthetic
  • support to attend appointments
  • transfer of responsibility
    • adult and cares
    • despite high level support from dental teams
  • knowledge, skills and attitudes of carer
  • training required
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26
Q

What barriers exist in professional services for patients with learning disabilities accessing dental care?

A
  • low confidence in the manage of people with learning disabilities by new graduates
  • inadequacies in professional training for dentists and therapists
  • dentists lack of experience
  • financial contraints due to NHS renumeration
  • carers belief dental services would prefer to see no-troublesome patients
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27
Q

What physical barriers exist for patients with learning disabilities accessing dental care?

A
  • access
    • physical
    • emotional
    • cost
  • travelling distance for specialist services
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28
Q

What cultural barriers exist for patients with learning disabilities accessing dental care?

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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29
Q

How can disability affect oral health?

A
  • people who take multiple medications may experience a dry mouth
    • increased caries risk
  • people with physical impairment may find it hard to clean their teeth or go to the dentist regularly
  • oral health issues are often over looked in health and social care planning for disabled people
    • lack of awareness amongst teams
      • protecting oral health
      • potential impact of medications on oral health
      • dietary advice given
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30
Q

Why is getting the place, time and person important for patients with learning disabilities accessing dental care?

A
  • place
    • where and when is assessment appropriate?
    • what treatment is safe and feasible?
    • what if a medical emergency or complication arises?
  • time
    • social context
    • transport
    • dental
    • environmental
    • medical disease
  • person
    • dependant on complexity of treatment
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31
Q

What barriers can be removed to improve access to dental settings?

A
  • ground floor access
  • suitable car parking
  • elevators
  • hand rails
  • wide corridors
  • disabled toilets
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32
Q

What tools can be used to improve access to the mouth?

A
  • Bedi shield
  • open wide mouth rests
  • toothbrush
  • mirror
    • must be plastic
      • shatterproof
    • not glass
  • good light
  • head support
    • ask consent
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33
Q

What is clinical holding?

A

the use of physical holds to assist or support a patient to receive clinical dental care or treatment in situations where their behaviour may limit the ability of the dental team to effectively deliver treatment, or where the patients behaviour may present a safety risk to themselves, member of the dental team or accompanying persons

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34
Q

What affects whether clinical holding is appropriate?

A
  • nature of the hold
    • proportionate to actions/behaviours
    • proportionate to risks
  • forcefulness, restrictiveness, duration
    • too much can cause distress
  • record keeping
    • must be thorough
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35
Q

What does assessment of a patient with a learning disability include?

A
  • level of understanding and intellectual function
  • communication
  • physical and emotional access
  • cooperation
  • medical status
  • social status
  • dental status
36
Q

What signs and symptoms should be watched for for people who cannot reliably report or communicate pain?

A
  • sleep interruption
  • changes in behaviour
  • rubbing of an area
  • pulling at an area
37
Q

What does dental status of a patient with a learning disability include?

A
  • cooperation
  • preventative regime
  • level of support
  • diet and method of delivery
  • swallowing and thickeners if appropriate
  • previous delivery of dental treatment
38
Q

How can capacity be demonstrated?

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 proposed treatment
  • retain memory of the decision
39
Q

What are the 5 principles of the Adults with Incapacity (Scotland) Act 2000?

A
  • benefit
  • least restrictive option
  • take into account the wishes of the person
  • consultation with relevant others
  • encourage the person to use existing skills and develop new skills
40
Q

What are examples of augmentative communication aids?

A
  • social stories
  • talking mats
  • makaton
  • picture boards
  • letter boards
  • wrist bands
  • draw or write
  • technology
41
Q

Who is involved in the oral care of patients with physical and learning disabilities?

A
  • carer
  • dietician
  • speech and language
  • oral health team
42
Q

What conditions can exhibit drooling?

A
  • developmental disabilities
  • cerebral palsy
  • progressive neurological conditions
  • Parkinson’s disease
  • Motor neuron disease
43
Q

What is dysphagia?

A

difficulty or discomfort swallowing

44
Q

What can increase dehydration and xerostomia for patients with dysphagia?

A
  • oxygen therapy
  • mouth breathing
  • side-effects of medications
  • reduced food and fluid intake
45
Q

What must be considered for patients with dysphagia?

A
  • pouching
    • holding food in the mouth
    • increased caries risk
    • especially buccally
  • moderation of consistency of foods and liquids
  • nutritional changes and sip feeding
  • risk of aspiration
    • increased with thickened drinks
  • sitting upright for consumption of foods or liquids
46
Q

What adaptations can be made to the oral care of patients with dysphagia?

A
  • support from carers and nursing staff
  • patient upright or semi-upright for toothbrushing
  • if spitting out is possible, encourage
  • suction toothbrush
  • hand-over-hand technique
  • regular dry mouth care
  • handle of second toothbrush to improve access
  • mouth guard or finger prop
  • adaptions to toothbrush handle
  • suction if trained to do so
47
Q

What are foam sticks and when are they used?

A
  • oral swab with foam head used in place of toothbrush
  • banned and have medical alert in the UK
48
Q

Why is oral hygiene still important for patients that are PEG fed?

A

although there is no substrate for caries, periodontal disease is still a risk so oral hygiene must be carried out

must be aware that some patients are given tasters so oral hygiene is required to prevent caries, tasting tools do exist to remove the caries risk but they did not take off

49
Q

What toothpastes are available for patients with physical and learning disabilities?

A
  • high fluoride
    • level of fluoride determined by risk assessment
  • non-foaming toothpastes
    • if assessment shows difficulty swallowing
  • unflavoured toothpastes
    • Oranurse
50
Q

Provide examples of SLS free toothpastes

A
  • sensodyne
    • pronamel
    • fresh mint
    • extra/true white
    • full protection
    • fresh impact
    • tartar control
  • oranurse
    • 1,450ppmF
    • 1,000ppmF
  • BioXtra
    • 1,500ppmF
    • dry mouth toothpaste
  • ultraDEX
    • 1,000ppmF
    • low-abrasion toothpaste
  • Youtuel
    • 995ppmF
    • sensitivity
  • Biotin
    • 1,400ppmF
    • dry mouth toothpaste
  • Oralleve
    • 1,450ppmF
    • ultra mild toothpaste for dry mouth
  • Aldi/Lidl
    • Dentitex/Dentalux
    • SLS free but contain alternative foaming agent
51
Q

What is the two toothbrush technique?

A
  • thick handled rubber toothbrush used between occlusion as a prop
  • gauze used to mop up mucosa and teeth
  • 2 person approach
    • 1 to support brushing
    • 1 to support individual
52
Q

What is Open Wide?

A
  • programe in Scotland empowering people with impairment and disability to look after themselves
  • patient/client centred
  • tailored to each individual’s needs
  • maximises capabilities of the individual
  • provides support where required in the most appropriate way
53
Q

What are the 3 units that make up Open Wide?

A
  1. Core Oral Health Knowledge
    • barriers and facilitators
    • common risk factor approach
  2. Practical Oral Care
    • adjuncts to communication
  3. Oral Health Documentation
54
Q

How can oral hygiene be supported for patients with physical and learning disabilities?

A
  • discuss at eye level in front of the person
  • pea-sized amount of toothpaste on small headed brush
  • access to mouth
  • systemic approach
    • outside surfaces
    • inside surfaces
    • chewing surfaces
    • mucosa
  • counting/singing
55
Q

What additional considerations are there for oral hygiene routines for patients with physical and learning disabilities?

A
  • timing
    • best time of day?
    • same time of day to develop routine
    • predictable
    • routine positively reinforced
      • accompany oral hygiene with enjoyable activity
  • environment
    • maintains dignity
    • light enough to be able to see
  • positioning
    • necessary support
    • comfortable, supported head position
  • forward and down
    • to reduce gag reflex and dysphagia
  • behavioural strategies
    • bridging
    • chaining
    • hand-over-hand
    • distraction
    • rescuing
56
Q

What is the behavioural strategy bridging?

A
  • helps to encourage a person with a task through their senses
  • helps with understanding
  • describe and show the toothbrush
  • mimic brushing own teeth
  • give individual their own toothbrush
  • attempt to achieve mirroring
57
Q

What is the behavioural strategy chaining?

A
  • gently bring the individual’s hand to their mouth
  • meanwhile describe the activity
  • carer starts activity and individual finishes it
58
Q

What is the behavioural strategy hand-over-hand?

A
  • place hand over individual’s hand and gently brush their teeth together
59
Q

What is the behavioural strategy distraction?

A
  • distract the individual by placing a familiar item in their hand
  • meanwhile brush their teeth
  • music can also be a helpful distraction
60
Q

What is the behavioural strategy rescuing?

A
  • if attempts are not going well the carer can leave and a rescuer can take over
  • a fresh approach with a new person may encourage the individual to cooperate
61
Q

How can toothbrush biting be tackled in patients with physical or learning disabilities?

A
  • allow the person to continue biting on one toothbrush
  • use another toothbrush to provide oral care
62
Q

How can tongue thrusting or tightly pressed lips be tackled in patients with physical or learning disabilities?

A
  • gauze square wrapped around forefinger
  • retract or hold tongue or lips back
  • requires patience and perseverance
63
Q

What oral care is required for patients that are tube fed?

A
  • oral mucosa should be kept moist and lubricated
  • teeth should be cleaned with a non-foaming toothpaste
  • consider an upright position
  • be aware of aspiration
64
Q

If there is resistance to oral hygiene what can be done to increase cooperation for patients with physical and learning disabilities?

A
  • alterations to brushes
    • small head
    • soft toothbrush
    • silk toothbrush
    • different toothbrush for each quadrant
    • dry brush
  • start at the back and move forward
  • toothpaste
    • flavourless
    • non-foaming
65
Q

Why might patients with physical and learning disabilities be resistant to oral care?

A
  • bleeding gums
    • reassure that it will reduce with improved OH
    • provide oral hygiene
    • seek further opinion if not resolving
  • pain
    • dental source
    • process of oral hygiene
  • stressors
    • environment
    • person
66
Q

What sensory aids are available for patients with physical or learning disabilities?

A
  • power suit
  • desensitisation
  • counting
  • interesting toothbrush
  • warm water
  • stories or books
67
Q

What appropriate denture hygiene advice can be given to patients?

A
  • dentures must be removed from the mouth
    • reduces risk of oral mucosal disease
  • rinse dentures after every meal
  • clean dentures morning and night
    • toothbrush
    • denture cream or plain soap and water
    • over filled basin or soft surface
      • reduce risk of breakage on dropping
  • soak dentures daily
    • disinfecting solution
    • 20 minutes
  • soak dentures overnight
    • plain water
68
Q

How can routines be developed for patients with physical and learning disabilities?

A
  • positive reinforcement
    • increased rate of behaviour as a result of the presentation of a preferred event or stimulus
  • negative reinforcement
    • increase in the rate of a behaviour as a result of the withdrawal/prevention of a non-preferred stimulus or event
69
Q

How can the habit loop be used to make oral care a positive habit?

A

cue –> routine –> reward

  • cue/trigger
    • time of day
    • environment
    • object
    • preceding behaviour
    • person
  • routine/repetition
    • 18-254 days to embed a new habit
    • average is 66 days
  • reward
70
Q

What factors can facilitate behavioural change?

A
  • supportive environment
  • stable environment
  • intervene in major change
  • piggyback (same time as other positive experience)
  • make it easy
  • unique personal cues
  • practise and repeat
71
Q

What does an oral health assessment include as part of the oral health documentation of open wide?

A
  • completed within 48 hours of being in residential care
  • risk assessment
    • identify risks to oral health
    • identify subsequent needs
  • natural teeth
  • dentures
  • current oral problem list
  • dental registration and attendance
  • medications
  • smoking status
72
Q

What daily oral care records should be held as part of the open wide programme?

A
  • record completed by carer
    • checked weekly be senior member of staff
  • aids identification of problems
    • enables a supportive response
  • review assessment
    • after 4 weeks
  • stored in central folder
    • allows easy access
  • valuable for dental team
    • allows for assessment of needs
73
Q

What is the Disability Distress Assessment Tool (DisDAT)?

A
  • method through which to understand an individual’s language of distress
    • identify usual content clues
    • distress cues identified more easily
  • observe the individual
    • facial appearance
    • jaw movement
    • appearance of eyes
    • skin appearance
    • vocal sounds
    • speech
    • habits and mannerisms
    • body posture
    • body observations
  • associated clinical decision checklist
74
Q

What factors influence whether patients with physical and learning disabilities are able to accept operative dental treatment?

A
  • cooperation and anxiety
    • can they accept care?
    • modality of treatment
  • safety and risk assessment
    • medical status
    • physical status/disability
    • emotional status
  • social status
    • dependance
    • support
    • maintenance of dental treatment
75
Q

How does sedation in special care dentistry differ to sedation for purely dentally anxious patients?

A
  • different set of skills required in assessment
  • patient ability to describe feelings may not be present
    • other assessment tooth required
  • risk with benzodiazepines
    • over sedation
    • respiratory depression
    • abnormal reactions
  • epilepsy must be well controlled
    • midazolam given for stopping seizures
76
Q

What different types of sedation are available and what are the advantages and disadvantages of each?

A
  • oral
    • patient required to take medication
    • can be disguised in a drink
    • can be unpredictable
      • bolus dose
      • pharmacodynamics can greatly vary
  • intra-nasal
    • increasingly used
    • no need to take medication orally
    • quick onset compared to oral
  • inhalation
    • patient requires understanding
      • breathing through nose piece
    • least risk associated with this modality
    • significant behaviour management required
    • issues with sustainability
    • same day assessment
    • suitable for medically compromised
  • intravenous
    • usually midazolam
    • drug titrated safely to maximum effect
    • risk of respiratory depression
    • significant benefits with muscle relaxation/involuntary movements
      • Huntington’s disease
      • cerebral palsy
    • ASA classification important
    • cooperation for cannulation
    • paradoxical reaction
    • 24 hour post op 1-on-1 care
    • multiple appointments required
    • broader range of treatment options
77
Q

In what special care patients is it more challenging to maintain airway during general anaesthetic?

A
  • obese patients
    • reduced airway patency
  • Down syndrome
    • shorter necks
78
Q

What risks are associated with general anaesthetic for dental use?

A
  • death
    • 1 in 100,000/200,000
    • increases with:
      • age
      • complexity of surgery
      • emergency/unwell before procedure
      • co-morbidities
  • brain damage
  • nausea and vomiting
    • usually immediately afterwards
    • can be up to 24 hours
  • shivering and feeling cold
    • few minutes to a few hours
  • confusion and memory loss
    • more common in elderly people
    • existing memory problems
    • usually temporary but can be longer lasting
  • bladder problems
    • difficulty passing urine
  • dizziness
    • fluids given to treat this
  • bruising and soreness
    • area where injected or drip fitted
    • usually heals without treatment
  • sore throat
  • lethargy
  • delayed recovery
  • allergic reaction to anaesthetic
    • anaphylaxis
  • waking up during procedure
79
Q

When could general anaesthetic be an acceptable treatment option for a patient with physical or learning disabilities?

A
  • significant volume of treatment required
  • patient uncooperative
  • medical complexity
    • patient managed in controlled and safe environment
  • oral health stable for 2-3 years post-op
    • predictable oral health
    • little risk of symptomatic dental disease
    • minimised risk for repeat GA
  • severe treatment plans
    • no crown or bridgework
      • unless extra-coronal can be placed without GA
    • no endodontics
      • pulp ally involved teeth extracted
      • strategic exception if good OH
    • teeth of poor prognosis extracted
    • opposing non-functional teeth removed
80
Q

Provide a brief overview of the process of a dental general anaesthetic

A
  • patients receive dental assessment
  • patient called to pre-op medical assessment
  • attend hospital for general anaesthetic
    • checked in
    • see anaesthetic team
    • dentist confirms plan and paperwork
    • pre-med given if required
    • anaesthetic team provide care
      • nasal tube
  • dental team
    • examination
    • radiographs
    • treatment planning
    • scale and polish
    • restorations
    • surgical and non-surgical extractions
  • other procedures while under GA
    • bloods
    • hair cut
    • toe nails cut
    • ear wax removal
81
Q

When should patients with physical and learning disabilities be referred for a general anaesthetic for dental treatment?

A
  • pain and swelling
    • where no alternatives exist
    • must be managed acutely
  • obvious dental disease
    • no alternative treatment modality available
  • number of years since reasonable examination
    • presence of poor oral hygiene
    • suspicions of disease
82
Q

What are the advantages and disadvantages of inpatient/outpatient treatments?

A
  • in patient
    • captive audience
    • preparation of patient
    • medical backup
    • post-op monitoring
    • piggy-back for holistic care
  • out-patient
    • reliant on independent variables
    • threshold for safety changes
83
Q

How are post general anaesthetic dental emergencies managed?

A
  • bleeding
    • local or medical
    • gain access to manage haemostasis
    • if not must access a GA list
  • post-operative infection
    • assess
    • antibiotics
    • GA for flush out and debridement
    • often antibiotics are preferable
84
Q

How can dental emergencies in uncooperative patients be managed to buy time?

A
  • reversible pulpitis
    • access for ART
    • temporisation
  • irreversible pulpitis
    • access for sedative dressing
    • antibiotics ineffective
  • periapical infection
    • antibiotics
    • plan for sedation or GA
85
Q

What is ART?

A
  • atraumatic restorative technique

BDS4 Special Care Dentistry (4 decks)

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