Rheumatology Tutorial

Question 1

what key features should be considered in the design of the practice and it’s facilities to enable those with limited mobility to access your GDP?

Answer 1

> Access

• Is there a ramp
• Is there stairs
• Is there a lift

> Space

• Is there room to turn ~ turning circle
• Space to sit in waiting room

> Disabled Parking

> Ability to get into the dental chair
- Depends on level of mobility ~ difference between limited and none

• Need appropriate wheelchair access
○ Ramp either permanent or temporary
○ Can get portable ramps for one wee step or can have a ramp built in

• How is she going to get to the practice?

• Disabled parking facilities?
○ Would be ideal
○ Unlikely in high street dentists

• Out of a car / taxi ~ how do they get onto the pavement
○ Lowering parts of all pavements at junctions to allow people to cross roads or cross roads
○ Flat curb section makes it easier for them to travel than negotiating high curbs

• What state is the roads / pavements in
○ Are there potholes?
○ Make sure there are no cracked or wobbly stones that are covered in moss (slippy when wet)

• Handrails
Can help person who can walk a little but might be disabled

• Get her into the building:
○ Push buttons to open doors
○ Door needs to open inwards
○ If she has to use the door instead of having it opened it for the handle for the door should be at the wheelchair users level

• Once she’s inside need to consider:
○ Reception desk ~ appropriate height
○ Hallway to the reception desk should be uncluttered so the way is not blocked

• Disabled toilet facilities
○ Need to be able to get a wheel chair in and a wheelchair out
○ Has to be ease of access for the wheelchair

Question 2

do you have a responsibility to facilitate access to healthcare facilities for patients

Answer 2

yes
treat all patients equally

• Moral responsibility
• But have to be sensible
• Facilitate her to access a healthcare somewhere but it might be that our practice is not the most suitable one for her

Question 3

what legislative framework which exists to enable the access and provision of care for all individuals and groups of people

Answer 3

• The Equality Act 2010
  • Provides a legal framework to protect the rights of individuals and advance equality of opportunity for all
  • Requiring public bodies to meet a new integrated equality duty
  • Strengthening protection from discrimination for disabled people
• DDA 2004
  Disability Discrimination Act 2004
  • The disability discrimination act (DDA) aimed to end the discrimination which many disabled people face
• The Mental Health Act
• The Mental Capacity Act

Question 4

define and explain the concept of reasonable adjustments

Answer 4

Reasonable adjustment = within your power to change

• Make it easier for someone carrying out day to day activities
• Changing how we do things, changing how our buildings are laid out
• Employers can no longer ask direct questions about disability unless they have a very good reason not to
• Can be physical
  ○ Changes to buildings
• Can be changes to attitude
  ○ By policies or procedures and staff training

Question 5

give an example of reasonable adjustment

Answer 5

• Ramp
• Hand rails
• Staff training day
• Loop system for hearing
  issues
• Better signage for patients with eye problems

Question 6

give an example of an unreasonable adjustment

Answer 6

• Something you cannot easily do or is too expensive for your practise to do
• Eg If it is an old building you don’t put a lift in
• Getting a lift put in for the 1st or 2nd floor
• Not possible or reasonable to expect a dental practice to do this

Question 7

if you were unable to make any reasonable adjustments what should you do for a patient looking to register with your practise

Answer 7

• Apologise that we cannot facilitate her
• Look for practise with appropriate facilities
• Refer her on to them / sign post them

Question 8

if the patient had registered with your practise for some time and over time you were no longer able to facilitate them what do you do

Answer 8

• It is then your responsibility to find her another practice to attend
• Not enough to just sign post her in this situation

Question 9

what are the possible options to aid a patient in transferring to the dental chair from the wheelchair

Answer 9

• Transfer boards
  ○ Called banana boards
• Hoist
  ○ Unlikely for GDP
  ○ Transferrable / portable hoists are big and bulky so would take up a lot of space
  ○ Ceiling hoists are found in special care dentistry
• Wheel chair recliner
  ○ Very expensive and bulky
• Reclining wheel chair
  ○ Want a temporary head rest for these patients to ensure they are supported

Question 10

what are the advantages and disadvantages to a transfer board

Answer 10

Need a brake like facility on your dental chair
Most chairs don’t have this
So it is difficult
Brakes have to be on the wheel chair

Slide board under patient
Other half of board is on dental chair with arm removed

Patient needs to be able to do this themselves
Need upper body strength to move

Often used for getting from wheelchair into car or taxi
Can easily go wrong

Question 11

what can be used with a reclining wheelchair to increase comfort

Answer 11

• Cushions to increase comfort
  ○ Patient comes in with these
  ○ Patient can be in a lot of pain
  ○ Don’t hurt your own head or neck or back treating the patient in a position that is awkward for yourself

Question 12

what is a turn table

Answer 12

• Patient needs to be able to stand up and support their weight
• Get patient onto turntable
• Rotate it
• Patient sits down
• Would want 2 staff beside patient to ensure no accidents

Question 13

what is the advantages and disadvantages with a wheelchair recliner

Answer 13

• Very bulky and expensive

- Work extremely well

Question 14

what are the advantages of the stand aid

Answer 14

• More expensive than turntable
• Knees and feet are support
• Sling over shoulders
• Always have 2 staff to prevent accidents

Question 15

what are the advantages and disadvantages of using a hoist

Answer 15

• Most patients don’t enjoy the hoist
  ○ Can be a scary experience for them
• Very safe if done properly
• Patient needs to be in the sling sitting in the wheelchair before they come in
  ○ Deliver slings before the patient presents for appointment
  ○ Different sizes of slings
  ○ Single use slings
  ○ Attachments for the sling need to fit the attachments for the hoist
  § Not universal attachments
• Sling comes up over the back of the head
  ○ Means sling in in the right position and supporting her
• Once she is secure, never hoist a patient on your own
  ○ Have at least 2 people
  ○ Depending on patient maybe have 3
  ○ Nurse holding handle ~ can be difficult to hold this down
  ○ Can tilt so need to have someone at the back
• When hoist is not in use it must be returned to docking station so it is charging
• Never use hoist single handled
• Need a lot of space to use a hoist
  ○ Unlikely to have one for GDP
• If patient needs hoisted then you might sign post them to get treated where hoist is available

Question 16

why would a patient with rheumatoid arthritis struggle with brushing their teeth

Answer 16

• Dexterity issues

- Hands get twisted (like claws)

Question 17

what appointment times mightn’t be useful for rheumatoid arthritis patients

Answer 17

Morning appoinments mightnt be ideal for disabled patients because it can take them a little bit to get going in the morning

ask what times would work best

Question 18

what is methotrexate and it’s side effects

Answer 18

• For rheumatoid arthritis
• Works by inhibiting the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines
• Immunosuppressant

• Side effects
○ Anaemia, 
○ appetite decreased, 
○ diarrhoea, 
○ drowsiness, 
○ fatigue, 
○ headache, 
○ increased risk of infection, 
○ skin reactions, 
○ throat ulcer

Question 19

what is dicolofenac

Answer 19

• NSAID
• For painful inflammatory conditions of the oral cavity and throat and/or following dental treatment or extraction
• Mouthwash
• This along with methotrexate can both increase the risk of neurotoxicity

Question 20

what is paracetamol

Answer 20

• Analgesic
• Side effects
• Skin reactions
• Overdose if take more than 4g a day

Question 21

what is prednisolone and it’s side effects

Answer 21

• Acute exacerbation of chronic obstructive pulmonary disease, mild to moderate asthma
• This given with diclofenac increases the risk of gastrointestinal bleeding
• Cortical steroid / systemic steroid
○ Is this worrying?
§ Not as much as a concern because it was 4months but we still need to be careful
§ We don’t have direct guidance for steroids
• What do steroids help us with?
○ Systemically = dampen down her inflammation to make her life easier
○ We don’t know how much she was taken
○ But she took it for 2 months 4 months ago

• We worry about steroids because we need to body to be able to make the cortisol and if the patient is on the stoerid for a long period of time the body stops making
○ Affects fight or flight reaction
○ Sometimes need to top this up in patients if they have been on it for a long time

• Side effects
○ Anxiety, 
○ cognitive impairment, 
○ Cushing’s syndrome, 
○ fatigue, 
○ fluid retention, 
○ headache, 
○ increased risk of infection, 
○ nausea, 
○ osteoporosis, 
○ dizziness, 
○ Kaposi’s sarcoma

Question 22

what antibodies confirms a diagnosis of sjogrens disease

Answer 22

Anti-Ro and Anti-La and rheumatoid factor

Question 23

what are the oral symptoms of sjogrens disease

Answer 23

§ Severe?

§ Recurrent swollen salivary glands or persistently swollen

§ Does she need to drink liquid to help her swallow foods

§ What is her salivary flow rates

Revise this ~ what is normal, stimulated and unstimulated and what you would expect with dry mouth salivary flow

Question 24

what can reduced incised opening be a problem with

Answer 24

Reduced incisal opening
= problem with TMJ
Arthritis in TMJ

Question 25

what are the possible differential diagnosis for dry mouth

Answer 25

• Medication / polypharmacy
  ○ Multiple drugs ○ Remember some drugs can cause hypersalivation (anti-psychotic drug)
• Diabetes
• Anxiety / stress / being worried
• Dehydration
• Starvation
• Cancer
  ○ Chemotherapy ~ transient dry mouth ie after treatment the mouth should return to normal
  ○ Radiotherapy ~ glands irradiated during treatment
  § Difficult to avoid this
  § Profound dry mouth, chronic and progressive
  § Never goes away just gets worse
  § Can get fibrosis = face and muscles hardens
  § Very profound dryness
  □ Causes caries / demineralisation because it is such an acidic environment
  □ Give diet advice
• Hereditary causes too
• Cystic fibrosis
• Inflammatory conditions
  ○ Lupus ~ autoimmune
  ○ Srogrens
• Infections

Question 26

what do you want the plaque index to be ideally

Answer 26

under 10%

Question 27

what suitable radiographs are possible with a patient who has reduced incised opening

Answer 27

• OPT
  ○ Not ideal when patient is in wheelchair
  ○ Much better quality if patient can be standing with support
  ○ Sometimes not good for anteriors
• Bitewings mightn’t be able to get into the mouth
• Size 1 periapicals for anteriors
  ~ Unless we can get OPT good quality there

Question 28

how can you make a grip out of lab putty for a tooth brush

Answer 28

§ Give to patient to hold
§ Impression of the hand
§ Stick a toothbrush into it to improve
§ Send to lab and ask them to flask that
§ Highly polished surface = much easier to keep clean
§ Long term use

Every 3 months screw in a new brush ~ more expensive because of lab fees but definitely helps

Question 29

can an electric toothbrush be of benefit to a patient with rheumatoid arthritis

Answer 29

○ Powered instead of one we have adapted
○ Can be easier to hold
○ Adapt handle
○ All she has to do is move it rather than actively brush