PMHP Flashcards
d3mft
obvious decay into dentine of tooth (using visual methods only)
3 fluoride population level deliveries
water fluoridation
fluoridated salt
fluoridated milk
components of clinical governance
6
Risk management
Education
Audit
Research
Clinical effectiveness
Openess
audit cycle
identify topic and set standards
obeserve practise and collect data
analyse data
implement changes
re-audit
PICO
population
intervention
comparison
outcome
RCT aspects
blinding of particpants and researchers
random allocation - computer generated
preordained outcome measures
inclusion and exclusion criteria
Risk ratio value of no difference
1
absolute risk difference value of no difference
0
things to consider when analysing a study
size of study
duration of study
population investigated in study
confounding variables
clinical governance
systematic approach to maintaing and improving the standard of pt care in a health system
dimensions of healthcare
6
Pt centered
Efficient
Equitable
Effective
Timely
Safe
3 dimensions of healthcare in NHS dental services
primary care - general practice and public dental service
secondary care - hospital
CPD hours in 5 year cycle
100 verifiable hours
CPD core subjects
10 medical emegency
5 radiology and radiation protection
5 decontamination and disinfection
GDC standards
- Put pt interests first
- communicate effectively with pt
- obtain valid consent
- protect pt inforamtion
- have a clear and easy complaints procedure
- work with colleagues in pt best interests
- maintain, develop and work within own skills
- raise concerns if pt are at risk
- behave professionally and maintain protect confidence in you and the profession
pillars of ethics
- non malicence
- beneficence
- justice
- pt autonomy
negligence
omission to do something which a reasonable practitioner would do, or doing something which a reaonsable practitioner would not do
how long should notes be kept for
10 years
or until child is 25
notes should be
7
confidential
accurate
legilible
complete
retrievable
current
retained
who is on the GDC board
1 chair
6 dental professionals
6 lay people
audit
quality improvement process that seeks to improve pt care and outcomes through systematic review of care against explicit criteria and the implementation of change
uses of audit
observe gaps in knowledge
learning
attitudes
protocol
training
audit cycle
identify problem and set standard
observe practice and collect data
analyse data
compare with set standards
implement change and re audit
factors that make up consent
informed
valid
capacity
voluntary
non-manipulative
non-coerced
discuss prior to consent
knowledge of purpose of tx
risks and beneftis fo tx
alternatives
no tx - risks and benefits
success rate
valid consent
3
recently obtained
specific to tx
remains current/continuous
legal consent
have capacity
has information
made and communicated freely - non coerced, non manipulated
study that gives highest level of evidence
systematic review of RCTs
cochrane review
4 aspects of RCTs
randomised
inclusion/exclusion criteria
control
blinding
cohort study
prospective
type of longitudinal study—an approach that follows research participants over a period of time
often share a characteristc
case control study
retrospective
observational study. It looks at 2 sets of participants. One group has the condition you are interested in (the cases) and one group does not have it (the controls). In other respects, the participants in both groups are similar.
case studt
one pt
detailed study of a specific subject
incidence
number of new cases over a specific time
prevalance
nummber of cases at a time
SIMD
scottish index of multiple depreivation - area based
tool for identifying area of poverty and inequality across scotland to support policy and decision making
ranks in order of dep (1 is most dep)
factors influenceing deprivation
unemployment/employment status
income
housing
education
access to healtcare
enviorment
crime
Adults with incapcaity act 2000
principles
Benefit
Minimal intervention
Wishes of pt
Others consulted
Residual capacity
Capacist
Assess option
Make decision
Communicate decision
Understand decision
Retain memory of decsision
who can consent under AWI 2000
welfare POA
welfare guardianship
or need section 47 certificate signed by adequately trained person
adv of split mouth design
both control and intervention exposed to same evironment
disadv of split mouth design
pt cannot be blinded
confidence interval
representation fo study findings to real world propulation
worked out using the effect size and the sample size relative to the true population
95% likelihood of repeat results
p-value
statistical significance of results,
usually null hypotheses
<0.05 is significant?
aetiology of DFA
parent/peer output
media
pain expectation
previous negative experience
uneducated on modern techniques
anxious presentation
negative
low pain threshold/flinching
fidgets
sweating
needing to go to toilet/making excuses
lack eye contact
cycle of behaviour change
precontemplation
contemplation
preparation
action
maintenance
with progress or relapse at any stage
management techniques for anxious pts
densensitisation
acclimatisation
CBT
progressive relaxation
tell show do
mediaction - anxiolytic meds or sedation
distraction
control
primary appraisal in stress
initial assessment of stressor
1 - irrelevant
2 - benign
3 - harmful/threat
4 - harmful/challenge
seondary appraisal in stress
reaction to primary appraisal
1 - harm
2 - resistance
3 - exhaustaion
reponses to stress
direct action, seek information, do nothing or coping
burnout
disengagment and exhaustation
often negative and dissatisfied (
coping mechanisms for stress
work life balance
exercise
education on stress
set own goals
know own limits
recommend alcohol per week
14units
2 alchol free days
2-3 units per day
screen for alcholoism
CAGE
cut down
annoyed at critisim/aggressive
guilty
early morning drinking
alcohol intervantion
FRAMES
Feedback
Responsibilty
Advice
Menu of options
Empathetic
Self efficacy
smoking pack years
20/day is 1 pack year
number per day/years
smoking intervention
5As
Ask
Advise
Assist
Assess
Arrange
sharing/disclosing info when
Consent from the patient: patient provides explicit consent for the disclosure of their information, the dentist is allowed to share the relevant information with the specified party or parties.
Legal requirement: e.g in response to a court order, subpoena, or other legal processes. Disclose only the minimum necessary information required by law and should seek legal advice if in doubt.
Public interest: compelling reason to believe that the disclosure of patient information is necessary to protect public health or prevent serious harm to others e.g cases of serious communicable diseases or instances where the patient poses a risk to the safety of others.
Safeguarding concerns: concerns about a patient’s safety or suspects abuse, they may be required to disclose confidential information to social services or the police, in order to protect the patient or others
Clinical audit or research: done in a way that protects patient confidentiality e.ganonymizing or aggregating the data so that individual patients cannot be identified.
Sharing information with other healthcare professionals: involved in the patient’s care, such as physicians, specialists, or other members of the dental team. Done on a need-to-know basis, and the shared information should be relevant to the patient’s treatment or care.
consent not required when
Emergency arises in clinical setting and it is not possible to find out pt wishes
* Tx you provide must be least restrictive for pt future needs
for as long as the px lacks capacity, you should provide ongoing care and if the patient regains capacity then explain what has been done and why
non technical reasons for adverse events
team management
team working
situration awareness
decsision making
70%
rest are clinical and structural factors
diversity
acknowledgment of alterity amoung people in terms of their community, culture, beliefs, life experiences and individuality
equality
faireness of oppurtunity and observing the rights of people to do so
equity
tx people justly, which doesnt mean tx everyone the same - those with an unfair disadvantage may required additional aid - quality of being fair and impartial
disabled person
has a physical or mental impairment
the impairment has a substantial and long term adverse effect on their ability to carry out nornmal daily activities
DDA 2004
protected characteristics
age
gender - identity, expression, reassignment
sexual orientation
marital status
disabilty
race
pregnancy or materinity
religious belif
equality act 2010
categories of discrimination
direct
indirect
associative
perceived
harrasment
victimisation
instruction to discrimination
oral cavity cancer areas
lip
tongue
gum
FOM
palate
oropharyngeal cancer areas
base of tongue
lingual tonsil
tonsil
oropharynx
pharynx
OCC incidence
More common in males by far
Incidence rises around 45 yrs, peaks around 70
Far more common in deprived areas
Oral cancers
* Males 1.8 times more likely
* 65-70 yrs 3.7 times more likely than younger
* SIMD 1 2.7 times more likely
risk factors for oral cancer
7
Smoking (if never drank, 2.13 times more likely) – duration worse than high quantity
* More laynx
Alcohol (if never smoked, 2.04 times more likely) – quantity worse than duration
* More oral cavity/pharynx
* Alcohol reduction in cancer risk emerges after 20 years
Interaction: PAR for tobacco and alcohol = 72% (61 - 79)
* 4% alcohol alone, 33% tobacco alone, and 35% combined
Genetics
**Diet/BMI
**
**Oral health **and dental care
Socioeconomic status
HPV 16 and 18 are ocogenic
* 25% oral cancer HPV infection, 80% oropharyngeal caner
smoking and perio
Anerobic bacteria high in smokers (p.ging, t.denticola)
Delayed wound healing
Vasoconstriction - mask gingival irritation
Impaired chemotaxis of immune cells
Cytokine production reduced
Enzyme catlase prodcution effected - bone loss higher
CAL
stain teeth
benefits of quitting smoking
4
Initial reduction in MI risk after 24hrs, then continues to drop
* Drop to ½ that of a smoker at a year
* 15 years same risk as someone not smoked
Improvement in respiratory health within 72hrs (bronchial tubes reduced inflammation)
Improvement in lung function 1-9months (cilia regrowth)
Reduction in cancer after 2-5years (1/2 of active smoker) – oral and lung
Reduction to never smoker in 20years
48hrs improvement in sense of smell and taste
negligence claims have a basis when
Duty of care was owed,
the duty was breached (standard of care),
that breach caused or materially contributed to damage (causation),
the damage was reasonably foreseeable and had negative consequences and effects
key principles of EBD
Ask
Align
Acquire
Appraise
Apply
PICO
population
intervention
comparison
outcome
case report/ series
Report on a single pt/series of pts with an outcome of interest
disadv - No control used
Can be used to ID new disease outcomes and generate hypotheses
case-control stude
Study involving people with a disease and a suitable control group of people without disease, look back in time to a particular risk factor in both groups and can be used to look at potential cause of disease
Confounding bias, recall/selection bias, selection of controls, time relationships
case-control study
Study involving people with a disease and a suitable control group of people without disease, look back in time to a particular risk factor in both groups and can be used to look at potential cause of disease
dusadv - Confounding bias, recall/selection bias, selection of controls, time relationships
cross sectional study
An observation of a defined population at a single point in time (or time interval)
Exposure and outcome are determined and measures at the same time
Used to estimate disease prevalence and to investigate potential risk factors
disadv - Causality, confounding bias and recall bias
cohort study
Used to measure exposure in an established group of individuals that develop disease (outcome of interest)
Estimate incidence and investigate cause of disease, determine prognosis and timing and direction of events
disadv - Controls difficult to identify, confounding bias, difficulty blinding, very expensive/time consuming, large numbers required (difficult for rare diseases)
RCT
clinical trial - GOLD standard for effectiveness and efficacy
specification of particpants (inc/excl criteria), control randomisation and blinding
diadv - difficult to design and conduct, not suitable for all research questions
systematic review or meta-analysis
compiling data from multiple RCTs
most scietifically sound form of research paper as results from mutliple different papers investigating same topic are collated, noted and analysed
absolute risk
incidence of disease amoungst people exposed to agent, assumes no risk to those not exposed
attibutable risk
difference between incidence rates in exposed and non-exposed groups, risks attributes to factor being investigated
relative risk
ratio of incidence in exposed group Vs non-exposed group
measurement of proportionate/realtive inc in disease rates of exposed groups
makes allowance for frequency of disease amoungst people not exposed to harmful agent
risk factor
environmental, behavioural or biological factor (confirmed by temporal sequence), usually increasing the probability of a disease occurring and if absent/removed, reduces probability
causative agent
external factor which results in disease in susceptible individuals
determinant
Attribute/circumstance which affects the liability of an individual to be exposed or when exposed to develop disease
confounding variable
minor variable which is left uncontrolled which may/may not have an effect on results
absolute risk difference
difference risk between groups
value of no difference ARD=0
indicating no benefit/risk to either group
* E.g. ARD 2.2 [-1.1 to 3.3] = not statistically significant as it overlaps 0; ARD 3.5 [1.1-6.0] = statistically significant as it doesn’t overlap 0
* When CI overlaps 0 indicates insufficient evidence for a difference between tx and control groups (evidence not statistically significant)
confidence interval
Range of values that the ARD will take in population
95% of time will contain true mean
overlaps the ‘value of no difference’ between treatments indicates that there is insufficient evidence for a difference between the treatment and control group in the population
number needed to treat
Number of pts that have to be trated to prevent ne pt from developing the disease/condition/outcome
1/ARD
risk ratio is
robability of outcome in exposed group Vs probability of outcome in nonexposed group
**Value of no difference is 1 **
E.g. RR 2.2 [1.1-3.3] = statistically significant as it doesn’t overlap 1; RR 1.5 [0.3-3.6]=not statistically significant as it does overlap 1
Sufficient evidence if CI do not overlap 1
types of epidemilogical study
3
descriptive
analytical
interventional/experimental
key roles of epidemiology
4
measure amount of disease
meansure distribution of disease
measure distribution of natural history of disease
assess peoples risk of disease, healthcare needs, assessment and service planning
prevalence
number of diseases cases in population at a given time
estimates can be obtained from cross-sectional studies or derived from registers
incidence
number of new disease cases developing over a specific period of time in a defined population
estimates can be obtained from longitudinal studies or derviced from registers
properties of ideal index
6
Clear and unambiguous
Objective
Reproducible
Not time consuming
Acceptable to pt
Amendable to statistical analysis
healthpromotion
framework
4 strategy types
Framework
1. Identify needs and priorities
2. Set aims and objectives
3. Decide best ways to achieve the aims
4. Identify resources
5. Plan evaluation methods
6. Set an action plan
7. ACTION – implement plan
Upstream policy – public place smoking ban, sugar tax
Midstream policy – dental health support workers, social prescribing
Downstream policy – chair side clinical prevention, smoking cessation services
Common risk factor approach - addresses risk factors common to many chronic conditions within the context of the wider socio-environmental milieu. Oral health is determined by diet, hygiene, smoking, alcohol use, stress and trauma.
symptoms of smoking withdrawl
irritability, depression, restless, poor concentration, inc appetite (weight gain), sleep disruption, light headedness
e-cigs
stimulate tobacco smoking through vaporised nicotine delivery without burning conventional tobacco
Adv – thought to be less toxic, successful in helping quit smoking as hand-to-mouth habit maintained as well as psychosocial aspect of addiction
Disadv – no long term studies so effects unknown, possible gateway to smoking/renormalisation of it
Only advised to current smokers that are trying to quit
resilience
process of adapting well in the face of adversity, trauma, tragedy and threats
general dental service people
3
principals
associates
traning grades (VT)
public dental service people
4
dental officers
senior dental officers
specialist dental officers
clincal directors/chief administrative dental officers (island boards)
secondary care (hospitals) people
4
core training
training grades (inc higher specialisty trainees)
associate specialists/speciliast dentists
consultants
vulnervable child
3
under 5
medically compromised
irregular attenders (only in pain)
signs of non-accidental injury
5
- Symmetrical
- Triangle of danger or involving ears/eyes
- Story doesn’t match up/keeps changing
- Different injuries at different points of healing
- Delay in seeking help
child abuse needs to be
3
significant harm
carer has responsibilty for harm
significant connection between carer and harm to child
categories of child abuse
5
physical
emotional
sexual
neglect
non-nutritional failure to thrive
UN convention on the rights of child 1989
Respected
Informed
Protected from abuse, neglect, exploitation
Secure - be and feel
Start in life
Say in life
Child and Young Peoples act 2014
GIRFEC – shared approach
* Named person for every child for single point of contact
SHANARRI wellbeing wheel
* Safe, health, active, nurtured, achieving, respected, responsible, included
protection of children (scotland) act 2003
PVG - list individuals unsuitable to work with children
national guidance for child protection in scotland
See
* Injury
* Mark
* Bruise
* Presentation – dirty, clothing
* Parent behaviour – hostile, aggressive to you, staff, child
Hear
* Parent interacts with child
* Comment in waiting rooms
* Told
* Third hand
DOING NOTHING IS NOT AN OPTION
management of child neglect
One department – preventative dental team management
Multi department – involving health visitor, GP, school
Referral to child protection department
Voice concerns to parent – don’t blame
Offer support – OHI help, money concerns
Set targets
Record in notes what have seen, heard or been told using the exact words.
Immediate danger -> Police: child protection removal and fill in form after(e.g.hit, illegal 2020)
referring and recording child protection issues or dom abuse issues
Discuss immediately with senior if available
Notification of concern (NOC)
Tell pt, unless cannot get hold of or immediate danger
Duty SW (social work)
Advice and support
Role of wider health team (healthcare visitors)
Recording of concerns and actions
Outcome from NOC
Dissent form decision made- seek advice
Domestic Abuse – NICE guidelines; NHS Gender Based Violence Action Plan
vulnerable adult
unable to safeguard their own interests through disability, metnal disorder, illness or physical or mental infirmity, and who is at risk of harm or self-harm, including neglect”
Adult support and protection (Scotland) Act 2007
Consider whether a referral needs to be made on their behalf
AVDR
ask
validate
document
refer
adult support and protection act 2007
short term effects of child neglect
physical health
emotional health
social and cognitive development
long term effects of child neglect
mental health problems - major depression
suicide
substance abuse
heart disease and diabetes
jail
adverse childhood experiences
potentially traumatic events that occur in childhood (0-17 years).
For example: experiencing violence, abuse, or neglect. witnessing violence in the home or community.
dental neglect
persistent failure to meet childs basic oral health needs, resulting in serious impairment in the child’ oral health and general health
* Failure/delay to present (obvious dental disease)
* Impact on child – bullied, sleep disturbance, disturbed eating
* Care offered but child not returned
sharps injury management
apply pressure and allow to bleed
wash don’t scrub
assess type of injury
risk assess source of blood
establish contact - occupational health, datix
AWARE
spikes protocol
setting
perception
invitation
knowledge
empathy
summary and strategy
breaking bad news
fluoride and caries
dose response relationship with caries reduction
F varnsih
22600ppm
4xyearly
water fluoridation
1ppm
toothpaste for 0-3
smear
1000ppm
toothpaste 3-6
1450ppm pea
toothpaste 10+ high risk
2800ppm pea 0.619%
sodium fluorride
toothpaste 16+ high risk
5000ppm pea 1.1% soidum fluoride
fluoride mouthwash
225ppm
0.05% sodium fluoride
at least 6+ need to be able to rinse and spint
