pmhp Flashcards
9 gdc principles
- put pt’s interests first
- communicate effectively with pts
- obtain valid consent
- maintain & protect pt information
- clear & effective complaints procedure
- work with colleagues in a way that is in pt best interests
- maintain, develop & work within your professional knowledge & skills
- raise concerns in pt at risk
- make sure your behaviour maintains pt’s confidence in you and the dental profession
5 As of EBD
Ask
Align
Acquire
Appraise
Apply
PICO
Population
Intervention
Comparison
Outcome
used to ask questions
neglect
persistent failure to meet a child’s basic physical / psychological needs resulting in serious impairment
dental neglect
persistent failure to meet a child’s basic oral health needs likely to result in serious impairment of child’s oral / general health & development
if you suspect child abuse (4)
- observe - child’s behaviour & injuries
- record - conversations & findings in pt notes
- communicate; with parent / carer - ask how they got injuries, does it match description, reason for delayed presentation
- refer (for assessment) - if still concerned speak to child protection for advice, follow up in writing & speak with health visitor if u5 and school nurse if >5
3 stages to managing dental neglect
- preventative dental team mx = single unit approach, set targets, keep records & monitor process
- preventative multiagency approach = liaise with other HCPs, child may be subject to common framework assessment, agree joint plan of action, r/v at set intervals, letter to health visitor if child u5 not attending
- child protection referral = in complex / deteriorating situations, follow local guidelines, refer to social services if required
prevalence
individuals affected by disease within particular period of time / point in time
incidence
no of new cases of a disease during a particular period of time
ottawa charter 5 key areas for action
- building healthy public policy
- creating supportive environments
- strengthening community action
- developing personal skills
- reorienting health services
clinical negligence
- dentist owed duty of care
- duty was breached
- which cause / materially contributed to damage
- this damage was reasonably foreseeable & had negative consequences
capacity
AMCUR
ACT
MAKE
COMMUNICATE
UNDERSTAND
RETAIN
consent (6)
voluntary
not coerced
not manipulated
informed
with capacity
valid
principles of AWI act 2000
- benefit adult
- minimum intervention
- take into account present & past wishes of adult
- consultation with relevant others
- encourage adult to exercise residual capacity
residual capacity
any decisions which the pt can make for themselves
who can consent for dental tx under AWI
- welfare power of attorney
- welfare guardian
what is risk
no of events of interest / total no of observations
what is odds
no events of interest / no without the event
relative risk ratio
probability of an outcome in exposed group : probability of outcome in unexposed group
absolute risk difference
0 is the value of no difference i.e. no benefit
it is the difference between groups (risk of the tx - risk of control)
to calculate it is the risk in the tx - risk in control of getting the outcome
odds ratio
1 is the value of no difference i.e. no benefit
calculated by dividing no who experience effect over no who don’t for both tx and control groups then divide these two to get odds ratio
confidence interval
a CI that embraces / overlaps / contains the value of no difference between treatments means there is INSUFFICIENT EVIDENCE for a difference between tx and control group.
4 design elements of RCT
- specification of participants (inclusion / exclusion criteria)
- control of comparison groups
- randomisation
- blinding
cross sectional study
observation of defined population at single point in time
disadv - confounding / recall bias / casuality
confounding variable
a factor other than the one being studied that may distort or mask the effects of another variable on the disease in question e.g. age
case control study
retrospective study of people with disease vs people without disease
looks back in time at exposure to particular risk factor
disadv - recall or selection bias / confounding / time relationships
case report
report on single pt or series of pts
no control group & no valid statistical associations
cohort study
establish group of individuals in population, measure exposures, follow up over period of time, identify those who have the disease
disadv controls difficult to identify / confounding / blinding difficult / large sample if disease rare / time consuming
rct
strongest evidence on effectiveness of tx
p value
used in stats to help determine significance of results
if <0.05 you reject the null hypothesis & your results are statistically significant
note - want narrow CI as larger the sample, smaller the CI
confidence interval
range of values that a true population tx effect is likely to lie
estimate of the amount of uncertainty of a sample
NNT
number needed to treat
no of pts needed to tx to get 1 pt to experience outcome so you want low NNT
4 main communication skills for guiding style
OARS
open questions
affirmations
reflective listening
summary
cycle of behaviour change
precontemplation
contemplation
preparation
action
maintenance
what is domestic abuse
any form of physical, verbal, sexual, psychological or financial abuse which might amount to criminal conduct & which takes place within the context of a relationship
types of abuse (5)
verbal
emotional
financial
physical
sexual
how to deal with domestic violence in practice
AVDR
ask - in non judgemental way
validate - removes blame, believing & taking seriously
document - specifically what pt says in notes in own words
refer - signpost to where they can seek help
why alcohol abuse causes problems in dentistry
decreased synthesis of clotting factors in damaged liver combined with reduced absorption of vit k dependent ones
thrombocytopenia due to splenomegaly associated with portal hypertension
megakaryocyte maturation decreased leading to fewer platelets
platelet aggregation reduced leading to prolonged bleeding
reduced drug metabolism for LA / analgesia / sedatives
alcohol limit M & F
<14 units / week spread evenly over 3+ days
screening tools for alcohol
- AUDIT - gold standard
- FAST - most practical
- PAT - used in A&E
what has reduced alcohol intake in scotland
ban on multi buy promotions
minimum pricing per unit
framework for action plan
increased investment in alcohol tx & care services
lower scottish drink drive limit
restricted hours of purchase
chairside interventions
5A’s - ask advise assess assist arrange
2A’s 1R - ask advise refer
ABIs - alcohol brief interviews
community based dentistry
population
I
community
I
individual
this goes from upstream -> downstream
upstream egs - childsmile, sugar tax
downstream - toothbrushing, FV, 8 elements of caries prevention
8 elements of caries prevention
- radiographs
- toothbrushing instruction
- strength of F in tp
- f varnish
- f supplementation
- diet advice
- fissure sealants
- sugar free meds
oral health impact of smoking
- increase in perio, alveolar bone loss, attachment loss, pocket formation
- increased risk of dry socket
- halitosis & xerostomia
- 2-4x increased risk of oral cancer
- black hairy tongue, smoker’s keratosis, nicotine stomatitis
general health implications of smoking
- narrows arteries & increased atherosclerosis
- increased risk of stroke
- increased chest infections / COPD / lung cancer / emphysema / bronchitis / increased stomach ulcers & cancer
- increased CHD / heart attacks
- macular degeneration & PVD
stress
acute pressure leads to specific reactions from nervous / endocrine system
hypothalamus responds by increasing cortisol
chronic stress leads to longer term high cortisol levels
thus effects on BP / immune system / hippocampus / memory / emotions
symptoms of stress
physical - exhaustion / GI problems / headaches / SoB / sleeplessness
psychological - touchy / irritable / lethargy / anger
summary of stress risk factors (6)
control
support
relationships
role
change
demand
burnout
process whereby a previously committed professional disengages from his / her work in response to stress / strain experienced in the job
3 scales of burnout
- emotional exhaustion
- depersonalisation
- personal accomplishment
what is resilience
process of adapting well in face of adversity / trauma / tragedy / threats
4 key ingredients of resilience
- reaching out
- rational thinking
- awareness
- fitness
critical appraisal
process of assessing & interpreting evidence through systematic consideration of its validity, relevance & results
use PICO to determine if trial addressed a clearly founded issue
CASP tool
critical appraisal skills programme
set of questions allowing us to go through paper asking if set results were valid & whether they apply for primary which is 1 paper on 1 study
systematic review
type of literature review that uses systematic methods to collect 2ndary data, critically appraise research studies & synthesise studies
designed to provide complete summary of current evidence relevant to research question
adv of SR
saves time
provides reliable evidence
resolves inconsistencies
explores differences between studies
identified when questions have been fully answered
identifies gaps
how does SR reduce bias
in gathering, summarising, presenting, interpreting & reporting of research evidence
key characteristics of SR (5)
- well formulated q (PICO)
- comprehensive data search
- unbiased selection & abstraction process
- assessment of papers
- synthesis of data
risk of bias assessment for RCT (6)
- sequence generation
- blinding
- selective outcome reporting
- other i.e. funding
- incomplete data outcome
- allocation concealment
reporting bias
publication
citation
time lag
language
what is blinding
concealment of group allocation from 1 or more of the individuals involved in trial
what is meta analysis
process of using statistical methods to combine results of different studies
aim is to integrate findings, pool data & identify overall trend of results it is an optional part of SR
what does meta analysis do (4)
- calculates tx effect based on pooled data from group of studies
- estimates common tx effect across studies
- improves precision of a point estimate by using all available data
- increases sample size
2 different types of data
- dichotomous - binary (is or is not) i.e. odds ratio, risk ratio, ARD, NNT
- continuous - bp / weight / amount of pain
vertical line on forest plot
where the tx and control have the same effect i.e. the value of no difference
diamond on forest plot
relative risk which is outcome of intervention / outcome of control
i.e. % who died with steroid / % who died with placebo
horizontal line at bottom of forest plot
the scale measuring tx effect
caution - read labels as to the left does not always mean that treatment to the left is better than the control
heterogeneity
differences between studies that may produce different results
3 types:
- clinical
- methodological
- statistical
to identify heterogeneity visually
if studies estimating the same thing we would expect CIs to overlap to a large extent so may appear in forest plot as poor overlap of CIs
therefore, can’t draw line through CIs as they don’t overlap so wouldn’t want to pool these
to test for heterogeneity
- chi squared test = P<0.1 demonstrates statistically significant heterogeneity so may not be appropriate to pool data
- I squared statistic = % variation due to heterogeneity rather than chance (<50% acceptable)
what does cochrane use to evaluate quality of body of evidence
GRADE
Grading of Recommendations Assessment Development & Evaluation
5 factors that lower the quality of GRADE
- high / unclear risk of bias
- inconsistency between studies i.e. heterogeneity
- indirectness i.e. PICO
- publication bias
- imprecision i.e. numbers & CIs
what is clinical governance
systematic approach to maintaining & improving standard of pt care within health system
6 factors of clinical governance
- clinical audit
- openness
- risk management
- clinical effectiveness
- education & training
- research & development
what is an audit
quality improvement process that seeks to improve pt care and outcome through systematic review of care against explicit criteria & implementation of change
5 steps of clinical audit
- identify problem
- set criteria standards
- observe practice / data collection
- compare performance with criteria / standards
- implement change
6 dimensions of health care
timely
efficient
effective
equitable
person centred
safe
consent must be
- valid -> recently obtained / remain current / specific to proposed tx
- legal -> ability i.e. capacity / informed / voluntary
7 factors influencing SIMD category
employment status
crime
housing
income
education
geographical access
health / health care services
what is an addiction
chronic, primary, neurobiological condition influenced by genetic, psychosocial and environmental factors
risk factors for drug misuse & addiction
genetic
socioeconomic
male
environmental
personality - low self esteem
social circles who are also drug users
method of drug admin
early exposure
stress
abuse
trauma
reward pathway
activated by rewarding stimulus i.e. food / water / sex information travels from VTA (ventral tegmental area) to nucleus accumbens and then up to prefrontal cortex
dopamine mediated transmission allows us to feel pleasure
2 variables on fluoride toxicity
- weight of child
- strength of toothpaste
management of fluoride overdose
<5mg/kg = calcium orally & observe for a few hrs
5-10mg/kg = calcium orally (milk / calcium gluconate) and admit to hospital
>15mg/kg = admit to hospital immediately, cardiac monitoring & like support, IV calcium gluconate
what is the position called for seating
balance / neutral position
- 90 degree angle at hip & bone
- thighs roughly parallel to floor
- feet on floor, back & neck upright
- shoulders relaxed
- move with chair, do not bend / twist / stoop
zones for right handed operator
imagine pt head is at 12 o’clock
7-11 = operating zone
11-2 = static zone
2-4 = nurse’s zone
4-7 = transfer zone
direct aspiration
- adjacent to tooth being treated
- aspirator placed slightly distal
- do not obscure view of operator
- bevel should be adjacent to tooth
- remove excess fluid at back of mouth
- do not go over tongue to access back of mouth
indirect aspiration
- useful if access limited or aspirator obscures view
- anterior 3-3 position aspirator on side closest to you
- if operator on LHS this would then be on lower right quadrant
- if operator on RHS this would then be on lower left quadrant
- remove water / debris without obscuring view
if dental dam on
3in1 should still be used
required for washing & drying teeth
keeps mirror clean and clear for indirect vision
5 methods of soft tissue retraction
aspirator
dental mouth mirror
tongue depressor
3in1
cheek retractor
for UR quadrant
3in1 retract & supports cheek
aspirator on palatal surface distal to tooth
for LR quadrant
3in1 retracts & supports cheek
aspirator between tongue and lingual surfaces
for UL quadrant
3in1 retracts & supports lower lip & cheek
aspirator retracts & supports cheek & is placed in buccal sulcus
for LL quadrant
3in1 retracts & supports lower lip
careful not to press lip onto teeth
aspirator retracts & supports cheek
anterior region
ensure lips retracted & protected
CW rolls
mouth mirror
support CW rolls with 3in1
to calculate NNT
1 / ARD
audit
quality improvement process which seeks to improve pt care and outcomes through systematic review of care against specific criteria and implementation of change
PEEEST dimensions of health care quality
person centred
equitable
efficient
effective
safe
timely
clinical governance
systematic approach to monitoring and improving quality of patient care / a framework which holds NHS accountable for continuously improving their services and safeguarding wellbeing
8 components of clinical governance
- education & training
- research & development
- clinical audit
- clinical effectiveness
- risk management
- enhanced significant event analysis
- openness
- peer review
