Special Care Flashcards
1
Q
What is special care dentistry?
A
concerned with providing and
enabling the delivery of oral care for
people with an impairment or disability
2
Q
What is the aim of special care dentistry?
A
The improvement
of oral health of individuals and groups
in society who have a physical, sensory,
intellectual, mental, medical, emotional
or social impairment or disability or, more
often, a combination of a number of these
factors
3
Q
Name the 3 groups who require special care dentistry (SCD)?
A
- People who experience disability
due to impairment of oral
function and/or structure
and who are limited in their
activity and/or participation
directly by their oral status - People who have a condition that
has direct or indirect repercussions
on their oral health - People who are disabled by their
social, environmental or cultural
context, which reflects on their
oral health.
4
Q
Is SCD continious or sporadic for pateints?
A
There is also a temporal factor, in that
SCD may be required at certain periods
or points of an individual’s life and not
at others
5
Q
How are treatment plans devised for SCD patients?
A
Tailored to meet their specific needs, is through an integrated care
pathway developed through liaison with
all those members of that individual’s
care team
6
Q
Name the 4 principles of dentistry?
A
- All individuals have a right to
equal standards of health and care,
including oral health
• All individuals have a right to
autonomy in relation to decisions
made about them
• Good oral health has positive
benefits for health, dignity and
self-esteem, social integration,
and general nutrition,
and
• The impact of poor oral health can
be profound
7
Q
Total number of disabled patients in the UK?
A
Between 8.6 and
10.8 million people
1/4 of us
8
Q
Inequalities in SCD - Do they occur? How do they occur?
A
Pateint’s with disabilities whom have the same avaliability for treatment, seemingly still have worse OH and are reccomended for extractions over indirect restorations or fillings.
Overall, they are treated differently to the rest of the population.
9
Q
Department of Health document detailing changes to dentistry which encompasses pateints with disabilities?
A
Valuing people’s oral health,
a good practice guide for improving
the oral health of disabled children and
adults (2007)
10
Q
Valuing people’s oral health,
a good practice guide for improving
the oral health of disabled children and
adults (2007) - what is included? summary? conclusion?
A
- recognises the need for the
provision of equitable and responsive
oral healthcare services for people with
disability - The document is designed to
support primary care trusts (PCTs) and their advisers in their needs assessment and commissioning of preventive oral health services rather than considering
treatment provision. - ‘it is important to value and develop competence
in provision of oral healthcare to people with disability through research,
consistent advice, professional training and provision of specialist care’. - It acknowledges the treatment of preventable dental diseases is costly to the PCTs
and specialist services and to patients
and their carers. It states that carers may
have to take time from work and fund
transport to accompany disabled people for treatment, but takes no account
of the emotional, psychological, social
or financial cost to the disabled person,
who may also need to take time from
paid employment1
11
Q
What’s wrong with the current NHS contract 2006, UDA system?
A
- in terms of ‘units of
dental activity’ (UDAs) that were being
provided in the test period of the development of the new contract. This remuneration system is based on average time
taken to carry out various procedures
rather than on the needs of individual
patients. It takes no account of the complexity of care, such as the provision of
oral care for someone with a learning
disability, which may involve dealing
with their inability to consent for care - UDAs have also been introduced into
the contracts of the salaried (formerly
known as personal and community) dental services, which have always been a
safety net service for people with disability unable to receive care in mainstream
general dental services. The new contract
has not taken account of the skewed practice profile of complexity of care within
salaried dental services and, not surprisingly, there has been anecdotal evidence
of the difficulties this has caused in continuing the appropriate provision of care
for people with disability. - in some areas, because of initial
uncertainty of how to approach the
issue, rather than rolling on contracts
for domiciliary care, none were commissioned thus reducing access to care
for vulnerable older people - Now, without additional commissioning of services by the PCT, any
further domiciliary care provided by a
practitioner is disincentivised as it will
be paid in UDAs, with no recognition of
the additional time or skills required.
12
Q
What is the case-mix model?
A
allows objective assessment of the complexity of the provision of care for people with disability through a structured
matrix.
13
Q
Name the 6 criterion in which the case mix model is based upon?
A
- Ability to communicate
- Ability to co-operate
- Medical status
- Oral risk factors
- Access to oral care
- Legal and ethical barriers
14
Q
Name the type of factor considered for - Ability to communicate?
A
Need for interpreter or other means of communication;
degree of learning disability or dementia
15
Q
Name the type of factor considered for - Ability to co-operate
A
Additional appointment time or acclimatisation visits required;
need to use sedation or GA
16
Q
Name the type of factor considered for - Medical status
A
Treatment modification required; degree of impact of medical
or psychiatric condition on the provision of care
17
Q
Name the type of factor considered for - Oral risk factors
A
Ability to carry out oral hygiene; dietary conditions, eg PEG feeding,
severe xerostomia
18
Q
Name the type of factor considered for - Access to oral care
A
Support of carer required to get to the surgery; use of wheelchair
recliner or hoist; need for domiciliary care
19
Q
Name the type of factor considered for - Legal and ethical barriers
A
degree of capacity to consent; need to consult with other professionals
or carers; need to hold best interest meeting or case conference
20
Q
The Disability Discrimination
Act 1995 - What did it include? update?
A
terms of alterations
to buildings and surgeries and changes to service delivery which may be reasonably expected of the general dental practitioner
2004
21
Q
The Equality and Human Rights Commission 2007 - what did it include?
A
Can use its new enforcement powers where necessary to guarantee equality to all.
Damages that can be awarded by them to a disabled person who has been discriminated against are seemingly limitless.
22
Q
The Disability Equality Duty 2006 - what did it include? name the 4 main categories?
A
It requires that any public body (including
service providers) needs to look actively
at ways of ensuring that disabled people
are treated equally
nsuring better physical access to oral
care for disabled patients can be divided
into four key areas:
• Access to the building
• Access to the dental surgery
• Access to the dental chair
• Access to the mouth.
23
Q
How to adapt practice to improve access to the building?
A
In many cases simple rails
and ramps will provide building
access for most people with a disability, and major alterations to buildings
are only required to provide full access
where they are considered reasonable.
the dentist’s
duty of care requires them to organise
alternative arrangements for treatment
which are reasonable and acceptable to
the patient.
24
Q
How to adapt practice to improve access to the dental surgery?
A
practice of ongoing and documented
disability awareness training for all
staff
1. Ask people with disabilities for their
opinions, and
2. Undertake an access audit.
Look at potential problem areas such
as the approach to the premises (parking, kerbs, ramps, lighting, signage,
etc). Examine the entrance including
door width, level threshold, door opening, position and design of door handles.
Include the reception and waiting room,
looking at the height of the reception
desk, clear signage, non-slip fl ooring,
communication aids, appropriate seating including chairs with arm rests, and
space for wheelchairs. Check there are no
obstructions or clutter in the corridors or
surgeries. Consider the design and layout of the surgeries to give wheelchair
access and manoeuvrability. Check toilet facilities, including space,
transfer bars, raised seat and alarm; and
consider means of emergency escape
from the premises including signage,
visual alarms and accessible exits.
25
How to adapt practice to improve access to the dental chair?
Aim, if possible, for the
surgery to be arranged in such a way
that there is room for a wheelchair to
be brought alongside the dental chair to
aid easier transfer by the patient into the
dental chair. This layout also allows for
the possibility of treating the patient in
their own wheelchair using a variety of
headrest attachments
As a general rule it is always prudent to ask the patient how much or little
help they require and not to assume that
they need help
When transfer is not straightforward, because the patient cannot stand
or weight bear, ‘transfer’ or ‘banana
boards’ can be used
A hoist is the best option for safe
and efficient transfer of patients unable
to do so independently, to the dental
chair
The base unit
offers the option of a dental mounting
joint for either a removable dental chair
or most commercially manufactured
manual wheelchairs. Once attached,
either option can be tilted, raised and
lowered with no compromise to posture
for either the dental nurse or the dentist whilst allowing patients to receive
dental treatment in a safe and comfortable position
26
How to adapt practice to improve access to the mouth?
To achieve the best position in the dental
chair, the patient’s body should be well
supported and joints and muscles should
be in the rest position.
for more complex patients she advocates the use of cushions or beanbags to aid in
patient positioning and comfort.
safe-guarder
'leg-relaxer'
bite support on finger for sporadic bitters
sturdier instruments
empathy for extreme gaggers
27
When thinking about the facilitators and barriers to special care, other than the physical environment, what else is there?
Capacity
• Financial
• Societal expectation
• Psychological/anxiety
• Medical history
• Communication
• Patient knowledge and attitude
• Professional knowledge and attitude – dental, medical, social care
28
Describe the SEAMLESS acroynm?
- S eamless
● E ducation and training
● A ccess
● M ultidisciplinary working
● L iaison and linkwork
● E mpowerment
● S pecial care dentistry
● S ervice provision and development
29
What is SEAMLESS?
Network to provide seamless care between different elements of dental services
• E.g. paediatrics to adult services, regular dentist to GA service
30
What factors can aid the SEAMLESS network?
Prevention to patient
• Carer training (Caring for Smiles, Open Wide)
• Undergraduate, Postgraduate, Continuing Professional
Development
• NEBDN Certificate in Special Care Dental Nursing
• Training for the dental team
- Medical emergencies
- Manual handling
Multidisciplinary Working
• Development of networks with other health and social care
professionals
• Sharing of information
• Eases anxiety if the correct information can be sought quickly
• i.e how to access emergency care
31
How can empowerment aid dentistry?
Patient centred care planning
● Many patients have personal health record which has information regarding likes,
dislikes, communication, every day needs
● Can also have oral care plan and tooth brushing
32
How to overcome the barriers in Dentistry?
Service Provision and Development
• Required if barriers to seamless care are to be overcome
• Some want to use mainstream services, others specialised
services
• Shared care model between GDS and Special Care Dentistry
• Multi-agency working
33
Act relating to consent?
Adults with Incapacity (Scotland) Act (2000)
34
What to discuss when trying to achieve informed consent for a patient?
Understand what the treatment is
• Benefits, risks and alternatives
• Consequences of not having the treatment
• Retain the information
• Communicate the decision to others
• Hold the decision consistently
35
What is the definition of in/capacity?
AWI defines capacity as when a person is incapable of:
1. Acting
2. Making decisions
3. Communicating decisions
4. Understanding decisions
5. Retaining the memory of decisions
36
How can capacity be affected?
Capacity may be diminished temporarily or permanently, partially or
totally
• Remember – the law in Scotland presumes all adults 16 years and older
have sufficient capacity to decide on their own medical treatment
37
What factors can influence a person's ability of capacity?
- Previous experiences
• Information
• Communication
• Pain, medications etc
• Conditions such as pneumonia, UTI, delirium
• Support
• Other people
• Adult Support and Protection (Scotland) Act (2007)
38
What does the Adults with Incapacity (Scotland) Act (AWI) cover?
• Whole act covers welfare, property, financial and medical
• Proxy decision makers
• Managing affairs in the future should capacity to make decisions lost
39
Name the 5 principles of AWI?
1. Any action taken on behalf of the person must benefit the person
2. Any action must be the least restrictive option that will achieve the desired effect
3. Before making a decision on behalf of a person, account should be taken of the person’s past and present views and preferences
4. Account should be taken of the views of specific persons such as guardian, attorney, relatives and any other person appearing to have an interest in the person
5. Anyone acting under the act must encourage the adult to develop and exercise as much skill as possible in making decisions or taking actions.
All steps must be taken to enhance the person’s decision making ability.
40
How to determine incapacity?
• Is capable of making and communicating their choices
• Understands the nature of what is being asked and why
• Has memory abilities that allow retention of information
• Is aware of any alternatives
• Has knowledge of the risks and benefits
• Is aware that the information is of personal relevance to them
• Is aware of the right to refuse as well as the consequences of refusal
• Has ever expressed their wishes relevant to the issue when greater capacity existed
• Is expressing views consistent with their previously preferred moral, cultural, family and experiential
background
• Is not under the influence from a relative, carer or other third party
41
What is Power of Attorney?
Power of Attorney – a person(s) granted the authority to make decisions on behalf of a person who becomes incapable of making decisions on their own
• The same way as a person creates a will
• Usually with legal help
• 2 types
- Continuing Attorney
- Welfare Attorney
42
What is the definition of a Continuing Power of Attorney?
Can only manage the finances and property of another person
• Powers can start immediately after the agreement signed
• The Granter can specify the powers should start only when they have lost capacity to manage their own finances
• Example of dental relevance – elderly resident of a nursing home having denture made as a dom, consent to treatment but not costs
43
What is the definition of a Welfare Power of Attorney?
Have the power of a person’s personal welfare (the things that affect the person’s physical and emotional well being)
• Medical care and treatment, choice of diet, personal care, clothing, meaningful social contact with friends and family
• Can only start making decisions, on behalf of the person, once the person has been assessed and it is agreed they no longer have capacity
44
What is the defintion of a Guardinship Order?
Can only be applied for when the person is assessed as not having capacity to make decisions
• Can cover property and financial matters or personal welfare including health or a combination of all of these
• Anyone with an interest in the person may apply e.g family member, local authority (social work)
• The decisions an Attorney or Guardian can make will be specified in the order granted, may not be all decisions
45
What is the definition of an Intervention Order?
Gives permission for one-off decisions which the person does not have capacity to make:
• Welfare intervention order may be relevant when a person is assessed as not being able to consent to complex medical treatment, although they can still make most other decisions
• Example of dental relevance – patient with complex psychiatric history requiring full mouth clearance under GA due to extensive caries and multiple periapical areas and recurring abscesses
46
Explain Part 5 of the AWI act?
Amended in 2005 to include dentists, nurses and ophthalmic opticians
• Must have relevant qualifications, experience and competence
• Can only authorise treatment in own speciality
• Practitioner allowed to share the authority to treat others involved in the person’s care and treatment
• Example of dental relevance – dentist authorises treatment plan to include scaling carried out by therapist and oral health instruction by the oral health educators
47
Explain Part 5, Section 47 of the AWI act?
Grants the practitioner the general authority to give medical treatment to an adult who lacks capacity to give or refuse consent
• Decision regarding capacity to consent should be based on assessment at the time rather than then existence if the adult’s diagnosis or disability
• Capacity to consent must be considered with respect to a specific decision and for a given moment in time
48
AWI flowchart?
look at it
49
What must a patient hold to prove Incapacity?
Adult with Incapacity Certficate
50
What must a valid AWI Act Certificate include?
Should it be deemed that the person does not have capacity to consent the Certificate of Incapacity under Section 47 of AWI (Scotland) Act 2000 is completed
• Must state how long it is valid for and must be signed and dated
- Treatment specific:
- it’s length should reflect this e.g. one day for dental GA, 3-6 months for restorative treatment plan, 3 years for examination, prevention (including OHI) and scaling
• Maximum period is 3 years
• Can be cancelled altogether or cancelled and changed should a person’s condition or circumstances change
• Good practice to attach a written treatment plan
• If the person who does not have capacity and there is a proxy, they can give consent on behalf of the person but a S47 certificate must still be completed
• If a proxy refuses consent, treatment cannot go ahead and practitioner must contact the Mental Welfare Commission for a 2nd opinion
51
Whom can give the Adults with Incapacity Certificate?
Dentists that have had the added training to gauge their capacity
- limited to the current treatment plan
52
What to do during an AWI emergency? Only Scotland
Identify whether the situation is an emergency? Yes
Over 16? Yes
Do they have capacity? No
Do they have a welfare guardian? Yes, contact them
If non-contactable, must try and relieve pain, but is mainly reversible
53
3 emergencies of dentistry?
Haemorrhage
Facial Swelling
Trauma
54
What happens if 2 welfare guardians can’t agree?
Must get a second opinion
Must find a consensus for the treatment
55
Welfare guardian vs PoA? Differences
Welfare guardian - patient has never had capacity
PoA - patient have had capacity in the last
56
What is the defintion of cerebral palsy?
Wide spectrum of non progressive neurological and physical disabilities
Developmental or as a result of peri natal insult suxh as hypoxia, trauma or infection
57
Name the 3 types of cerebral palsy?
Spastic
Ataxic
Dyskinetic
58
Describe spastic cerebral palsy?
Muscles appear stiff and tight
Arises from motor cortex damage
Most common
59
Describe dyskinetic cerebral palsy?
Involuntary movements
Arises from basal ganglia damage
60
Describe ataxic cerebral palsy?
Shaky movements. Affexts balance and sense of positioning in space
Cerebellum damage
61
Name the 4 types of coverage for cerebral palsy?
Monoplegia
Hemiplegia
Paraplegia
Quadraplegia
62
What are the dental features for a patient with cerebral palsy?
Higher level of untreated disease
Develolmebtsl abnormalities
Malocclusion
Uncontrolled movements
Bruxism
Drooling
Periodontal disease
Caroes
63
What is the defintipj of multiple sclerosis?
Complex autoimmune neurological condition which occurs as the result of damage to the myelin sheath of the nervous issues
Affafts both motor and sensory transmission
Relapsing or progressive
Weatern
20-40
More women
64
Neurological symptoms of multiple sclerosis?
Visions problems
Numbness or weakness
Facial pain or trigeminal neuralgia
Speech, swallowing and hering problems
Spasticity, spasms and tremor
Fatigue
Depression
65
Dentalnmanagement for a patient with MS?
Shorter appointments- their best tine
Rigours prevent
Wheelchair access
Dysphagia control
Cannabis use?
Dizzy and vertigo control
66
What is the defintion of Huntington disease?
Inherited progressive degenerative neurological disorder
Autosomal dominant
30-50
Death 15-20 years after onset
Pneumonia the killer
67
Name the physical symptoms of HD?
Uncontrollable muscular movement- stumble and clumsy
Chorea
68
Name the cognitive symptoms for HD?
Lack of concentration
Short term memory lapses
Lack of interest and organisation skills
69
Name the psychological symptoms for HD?
Depression
Mood swings
Frustration
Loss of flexibility
70
How to manage HD dentally?
Preventative regime
Dietician discussion
More basic treatment
IV conscious sedation
Trauma to lip die to choroid movement
Check consent
Respect wishes
71
Patients that need addition help for oral care?
MS
Arthritic
Stroke
Cerebral palsy
72
Name 3 diseases that effect periodontal health?
Medications suxh as antiepileptic
Diabetes
Cardiac disease
73
Things that will make dentistry harder to SCD?
Dento facial anomalies
Open kip posture
Mouth breaking
Short roots and crowns
Severe early onset perio disease
Impaired inflammatory response
74
Name 3 medically induced gingival hyperplasia?
Phenytoin - antieplileptic
Ca ch blocker - nifidipine
Ciclospirin - transplant drug
75
Describe gingival hyperplasia?
Pink and firm
Don't bleed easily
Treat with education, OHI and scalinf
76
How is the oral micoobiome affected by tube fed patients?
Reduction in oral stimulus and changes in saliva constituents
Calculus build up
Carer education
Aspiration risk
77
How to control plaque for a SCD patient?
Education
Adaptations to toothbrush
Chlorhexidine my
Frequent scaling
78
Describe an enhanced prevention plan for oral hygiene for a SCD?
OHI
Higher fluoride toothpaste
More frequent recall
Education
Empower the patient
79
Name the 4 doee programmes for education in SCD?
Caring for smiles - dependent elderly
Open wide- 16-64 with additional needs
Mouth Matters - prisoners
Smile4Life - homeless
80
What help do people with learning disabilities need?
o Understand new or complex information.
o Learn new skills
o Cope independently
81
Ratio of people with LD across 2000?
40 mild or moderate
8 will be severe or profound
82
Name causes of learning disabilities?
• Pre-natal, e.g. Drug/alcohol abuse, infection during pregnancy.
• Natal, e.g. difficult birth causing hypoxia.
• Post-natal, e.g. Infection (meningitis), or trauma.
• Genetic condition, e.g. Down Syndrome, Fragile X
• Idiopathic (unknown)
83
Name specific impairments associated with LD?
• Understanding
• Problem solving
• Communication
• Sensory
• Motor skills
• Delayed development
• Self direction
• Emotional Regulation
• Self Care
• Coping Strategies
• Self Awareness
84
What is the definition of a mild disability?
Have Speech for everyday purposes / hold conversations. However
can lack comprehension.
• Independence in self care - eating, washing, bowel/ bladder, rate of
development may be slow.
• Difficulty with formal Learning, such as reading and writing .
• Underdeveloped coping strategies- Noticeable emotional, social
immaturity.
• Difficulty in transferring skills.
• IQ = 55 - 69
85
What is the definition of moderate disability?
• Slow in developing comprehension, use of language.
• Self care skills limited; supervision required throughout life.
• As adults usually able to do simple practical work if tasks structured
and skilled supervision available.
• Complete independence is rarely achieved.
• Generally fully mobile, physically active and shows evidence of social
development, e.g. communication and social activities.
• IQ = 45 - 54
86
What is the definition of evere disability?
• Very limited communication, keywords only
• Lack of self-help skills
• May have additional physical disabilities
• Will require full time support
• IQ = 25 - 44
87
What is the definition of profound disability?
• Individuals are severely limited in ability to understand or comply with
requests, etc..
• Usually severely restricted in mobility and continence
• Rudimentary forms of non-verbal communication used
• Little or no ability to care for basic needs and require constant
supervision
• IQ below 25
88
Name the difficulties associated with learning disabilities?
• Motor problems - mobility, gross and
fine motor skills.
• Continence.
• Epilepsy - the greater the degree of
neurological damage, the greater the
severity and incidence of seizures.
• Vision.
• Hearing.
• Speech difficulties.
• Memory problems.
• Concentration and attention problems.
• Communication
• Understanding of social skills - anti
social behaviour.
• Understanding relationships and
emotions.
• Behavioural problems.
• Sleep problems.
• Psychiatric conditions.
• Eating difficulties.
• Self-injurious behaviour.
• Aggressive behaviour
89
How to communicate effectively with a person with a LD?
Speak slowly and as clear as possible
• Keep questions simple & only ask one at a time.
• Give specific choices which require “Yes” or “No” answers if appropriate
• Use visual clues such as Photographs
• Give the person more time to respond.
• Only give one instruction at a time
• Beware of literal interpretation of language
90
WHat are the top tips for communcation with a patient having a LD?
Speak slowly and as clear as
possible
2. Find a good place to communicate
in, lessen distractions
3. Check with the person that you
understand what they are saying
4. If the person wants to show you
something – go with them
5. Watch the person (non verbal
cues)
6. Keep communication simple use key word
Beware of literal interpretation
8. Learn from experience, ask carers
for help
9. Try drawing
10. Use gestures & facial expressions
11. Be aware that some people may
find it easier to use real objects to
communicate
12. Take your time
91
Describe a positive environment have on a patient with a LD?
Well organised, with structured activities and routines
• A stimulating environment offering opportunities for participation in
activities.
• An emphasis on positive and constructive communication and interaction
between staff and clients.
• Clear plans for activities based on client need.
92
What to assess during your clinical appointments for a patient with a LD?
Be aware that the patient may have had previous negative experience
before hand.
• If carers advise you that this individual has a fear or lack of tolerance
consider the following:-
• Waiting times
• Graded exposure/ Desensitization work
• Pictorial reinforcers of what is to happen (social story)
93
Describe the process of desensitisation? for a patient with a LD?
• Where the Patient visits the clinic prior to appointment
• They see the waiting room and examination area.
• It may take several visits to lesson anxiety.
• Allowing Patient to see/touch equipment etc.
• Sit in chairs in the clinical area.
• Start with non-threatening items.
• Less is best; do not over stimulate.
• Don't give too much information in advance.
• Use clear positive communication.
• Have a clear action plan, made in liaison with carers.
• Offer debriefing where possible.
94
Tips for a successful acclimitisation appointment for a patient with a LD?
Change can be difficult for most people to cope with, but for individuals
with LD even minor changes can cause major distress.
• Plan ahead, consider small steps
• Enhance understanding with visual aids, keep it concrete, transitional
objects.
• In the event of unplanned change consider careful communication,
reassurance and future planning. These things may make a difference
95
What attitudes should the team show to a patient with a LD?
• Non Judgmental
• Non Discriminating
• Responsible / using common sense
• Empowering
• Being aware of your own values/culture and those of others
• Good communication - verbal and non verbal
• Listening
• Being approachable
• Providing suitable resources
96
Describe differents in diagnosis of mental disorders?
Diagnosis on basis of syndromes not single symptoms
“Biopsychosocial model” - account taken of patient’s personality and culture as well as biology
Diagnostic manuals –l ists of conditions and their features provide criteria for diagnosis (ICD-10, DSM-5) – “operationalized"
97
Describe the aetiology of mental disorders?
Multifactorial – genetic and environmental (abuse/neglect/trauma) risk factors
Disorders can
- overlap (e.g. Neurodevelopmental Disorders)
- evolve (Bipolar Disorder)
Disorders may be final common pathways
- Depression (familial v life-events)
- Schizophrenia
Overlap with normal experience
- e.g. depression, anxiety
98
How to take a good history to garner information on mental disorders?
History of Presenting Complaint
Social History
Family History
Past Medical History – esp. illness which may mimic psychiatric illness e.g. hypothyroidism
Past Psychiatric History – admissions, treatments, complications
Personal History – Birth, childhood, school, work, relationships, forensic history
99
Describe the categopries included for a mental state examination?
Appearance and Behaviour – attire, self-care, agitation
Speech – rate/rhythm/volume
Thought Form e.g. tangential, concrete, flight-of-ideas
Thought Content e.g. preoccupations, delusions
Mood e.g depressed, euthymic
Perception (sensory) e.g. illusions, hallucinations
Insight – patient’s view of their symptoms
Cognition i.e. orientation, memory, language, visuospatial abilities (construction), abstract reasoning, executive functioning
100
Name the simple invesitagations that may give reason to mental disorder?
Depression – TFT, FBC, glucose
Dementia – FBC, U&E, LFT, TFT, B12&Folate, glucose
Neuroimaging (CT/MRI)
101
Describe the possible bioloigcal treatment for mental disorders?
Antidepressants (5HT,NA); Antipsychotics (DA); Mood stabilizers; Sedatives; Dementia drugs
Some may have significant side-effects, esp. if used long-term
102
Describe the possible psychological treatment for mental disorders?
e.g. Cognitive Behavioural Therapy (CBT), Psychodynamic psychotherapy, Counselling
Not free from adverse effects
103
Describe the possible social treatment for mental disorders?
e.g. exercise, groups, employment, “wellbeing” interventions
104
What is the definition of capacity?
Capacity is ability to make reasoned decisions about finances and welfare (includes medical & dental Rx)
Capacity is assumed
Sometimes worth questioning if mental illness is likely interfering with capacity to consent to treatment
105
What can impede capacity?
In Scotland, must have a psychiatric or physical condition which prevents decision-making by impairing (one or more of):
- Comprehension
- Weighing up information
- Memory
- Communicating decisions
- Acting on decisions
106
Describe psychosis - specific features and causes?
Loss of contact with reality
Specific features:
- Delusions (fixed false beliefs)
- Hallucinations (false perceptions)
- Disordered thought-form (thinking-patterns)
Not a specific illness
Causes:
- Mood disorders, schizophrenia, organic conditions
107
Give a description of schizophrenia? - prevalence? positive symptoms? negative symptoms? treatment?
“Fractured mind” not “Split personality”
Prevalence - 1% of population
“Positive” symptoms – psychotic symptoms – DA overactivity
- Delusions – usually paranoid
- Hallucinations – auditory – 3rd person
- Thought-form disorder
Disturbed behaviour
Negative” symptoms – DA underactivity
- Lack of thoughts, absence of emotion, lack of drive, social and occupational difficulties
Cause disability
Treatments
- Antipsychotics – DA blockers – for positive symptoms
- Rehabilitation (non-medical interventions) if negative symptoms causing ongoing disability
108
Give a description of dementia? - prevalence? positive symptoms? negative symptoms? treatment?
Not a normal part of ageing i.e. not normal age-related memory decline
Cognitive decline (not just memory)
Functional decline
BPSD (Behavioural and Psychological Symptoms of Dementia) e.g. anxiety, depression, hallucinations, unusual preoccupations, repetitive behaviour
Progressive
Types
- Alzheimer's, Vascular, Lewy Body Dementia, Fronto-Temporal Dementia
Decreased Acetyl-Choline functioning
Treatment
- Exclude reversible causes
- Medication for Alzheimers e.g. Donepezil, Galantamine, Rivastigmine, Memantine
- Social Care
109
Give a description of delirium? - prevalence? positive symptoms? negative symptoms? treatment?
Acute confusional state
- Disorientation
- Delusions – usually change rapidly
- Hallucinations – usually visual e.g. delirium tremens
- Hyperactive/hypoactive
Often fatal (up to 40%)
Not an illness in itself
Caused by an underlying organic condition e.g. infection, metabolic disturbance, drug withdrawal, head injury
Often occurs in the elderly due to pre-existing poor cholinergic (acetyl choline) function
Treatment:
- Investigate and treat underlying cause
- Good nursing
- Sedation if necessary – using antipsychotics - not Benzodiazepines (BZs) in the elderly
- Delrium Tremens (“The DTs”) - BZs
110
Give a description of depression? - prevalence? positive symptoms? negative symptoms? treatment?
Not just unhappiness
Syndrome
Core features; low mood, limited enjoyment, low energy
Other symptoms; poor sleep, poor appetite, poor concentration, tearfulness, low libido, negative thoughts, suicidal thoughts
Thought to be associated with Serotonin (5HT) and Noradrenaline (NA) underactivity
Causes – (there isn’t always a “reason” for depression)
- Psychological
- Social
- Biological
Complications
- psychosis
- suicide
- social and occupational problems e.g. loss of job or relationship
- chronicity
Treatment
- Mild – Psychological treatments (usually based around CBT, can be using books, online or by telephone)
- Moderate, Severe – Medications, Electro-Convulsive Therapy (ECT)
111
Describe the drug treatment for depression?
First line – Selective Serotonin Reuptake Inhibitors (SSRIs). Safe, minimal side-effects, few interactions. Act on 5HT.
Second-line – Venlafaxine, Mirtazapine (5HT and NA)
Other agents (various actions, less effective)
Combination/Augmentation with 2nd antidepressant, lithium, some antipsychotics, T3, Tryptophan
Tricyclic antidepressants – lethal in overdose, uncommonly prescribed
Monoamine Oxidase Inhibitors (MAOIs) – dietary restrictions due to potential for hypertensive crisis (tyramine – “cheese reaction”) but also interacts with analgesics and agents used in anaesthesia. Rarely prescribed.
112
Give a description of bipolar affective disorder? - prevalence? positive symptoms? negative symptoms? treatment?
“Manic depression”
Alternating episodes of depressed and elevated (“mania”) mood
Episodes are syndromal
Core feature; elevated or irritable mood
Associated features;
- over-talkative, over-sociable, increased energy, grandiose schemes, subjectively clear and rapid thinking, over-spending, promiscuity, risk-taking
Delusions and hallucinations if psychotic
Generally avoid antidepressants
Mood stabilizers
- Lithium
- NSAIDs toxicity
- metronidazole toxicity
- Valproate, Carbamazapine
- Lamotrigine
Antipsychotics e.g. Quetiapine
113
Describe anorexia?
Abnormal body image
Food restriction and other behaviours to reduce weight
Low body weight (BMI < 17.5)
Sexual
- Amenorrhoea/sexual dysfunction
- If onset prepubertal, failure to develop secondary sexual characteristics
114
Describe bulimia?
Binge eating/ preoccupation with food
Behaviours to reverse weight-gain
- Including but not limited to self-induced vomiting
“Morbid dread of fatness”
115
Describe the presentation of eating disorders at the dentist?
May first present to dentists
Signs
- Russell’s sign
- Erosion of dental enamel
- Erythema of mucosa
- Periodontitis
- Salivary hypofunction
May result in death
116
Describe the causes and treatment of eating disorders?
Causes
- Mainly psychological and social
- Pressure to be thin from social groups, preoccupation with ideals of perfection, need to exert control, family difficulties, low self-esteem
- Some of the associated symptoms and behaviours are seen in starvation (abnormal behaviours around food, abnormal cognition, self-harm) and may be a result of poor nutritional intake
Treatments
- Re-establish nutrition
- Psychological therapies
- SSRIs (bulimia)
117
Describe the misuse of substance disorder?
Currently, addictions are seen as a medical disorders which affect the brain and change behaviour – possibly due to dysfunctional reward systems (DA)
Use of alcohol and substances
- effect judgement, decision-making, learning, and behaviour
- can lead to self-reinforcing repetitive addictive behaviour
(Though why some individuals are more pre-disposed is unclear)
Treatments based on harm reduction and stabilization rather than abstinence
118
Describe the features, signs for alcohol dependence syndrome?
Features
- compulsion, salience, tolerance, loss of control, continued use despite evidence of harm, withdrawals
Physical signs
- Flushed complexion, coarsening of facial features, sweating palms
- Stigmata of liver disease such as finger clubbing, jaundice, bruising, ascites
Blood tests
- Raised MCV (FBC)
- Raised GGT (LFT)
Treatment – detoxification, then drug and non-medical interventions to support abstinence
119
Describe the complications of alcohol dependence?
Acute intoxication - injury
Withdrawal can be fatal
- DTs
- Convulsions
- Sudden cardiac death
Social and occupational problems
Physical health problems
Psychiatric complications
- Depressive symptoms, memory problems
120
Describe the categories, symtpoms and tretament for anxiety disorder?
Categories
- Specific phobias – fear of the dentist
- Generalized anxiety disorder
- Panic disorder
Symptoms
- Emotion (“anxiety”, fear)
- Thoughts (worries)
- Physical symptoms (e.g. palpitations)
Treatments
- CBT
- SSRIs
121
Describe peronality disorder?
Deeply-ingrained maladaptive patterns of behaviour which cause distress for the individual or for society around them
Extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others.
Lifelong - present by late adolescence or early adulthood
122
Describe borderline personality disorder - core features?
“Emotionally Unstable Personality Disorder (EUPD)”
Core features
- Extreme emotional instability
- Impulsive behaviour
- Intense but unstable relationships with others
- Fear of abandonment.
- Unstable self-image.
- Self-harm.
- Chronic feelings of emptiness
- Explosive anger
- Feeling suspicious or out of touch with reality
Psychotherapy (various modalities and “tiers”)
Medications may have some limited benefit
123
Describe the oral findings for a patient with schizophrenia
Poor OH
High caries rate
Periodontal disease common
Decreased saliva flow (long term neuroleptics)
Tardiness dyskenesia
Acutw dystopia (facial grimacing, tongue protrusion and neck stiffness)
Delusional oral symtpms
124
Describe the dental aspects for a schizophrenic patient?
Impaired gag reflex - protect airway
Approach slowly and non-threatening manner - explain what to expect
Be open - speak normal volume - paranoia
No elective treatments
Sedatives used with caution - synergistic with neuroleptics
Shorter apps
Care with smoking cessation - clozapinw lead to toxicity
125
What are the oral findings for a patient with depression?
Dry mouth
- due to meds (antidepnor lithium)
- oral candidosis
- increased caries risk
Facial dyskinesias
- occasional side effects of monoamine oxidase inhibitor
- invol move of mouth, lips or tongue
Atypical facial pain
Burning mouth
Sore tongue
TMJ pain dysfunction syndrome
126
What are the dental aspects of a patient with depression?
Use tact, patience and sympathy
OH neglect
Tricyclic and MAOIs can cause postural hypotension
MAOIs make GA a risk due to prolonged resp depression, also dangerous with many analgesics
127
What are the dental aspects for a patient with bipolar disorder?
Manic disorder
Mania - period of elevated mood
Depression - period of low mood
Difficult to manage
Lithium cause dry mouth
NSAIDs, metronidazole, tetracycline induce lithium toxicity
128
Name 4 psychiatric illness with dental signs?
Eating disorder
Hypocondriasis
Psychogenic pain
Substance misuse
129
What are the dental aspects of eating disorders?
Erosion of teeth (lingual/palatal and occlusal surfaces)
Petechiae/ulcers/abrasions particularly in the soft palate (cause by fingers/other objects used to induce vomiting
Xerostomia
130
Explain how to manage a patient with an eating disorder?
Poor compliance and associated behavioural problems
Use pain from enamel erosion as reason not to eat
GA/Sedation may not be safe due to medical problems
Rising with bicarb after vomiting may reduce the damage to teeth
Topical fluoride to reduce sensitivity
131
Why is domiciliary dental care necessary?
Legislation to protect vulnerable members of society from discrimination
- Equality Act 2010
Dentists must take reasonable steps to allow access to dental care
132
Domiciliary care GDC standard?
1.6.3
- you must consider patients disabilities
133
Name the 6 categorises of patients whom require domiciliary care?
- unable to access routine surgery based care
- elderly
- severe learning disabilities
- physical disabilities
- psychiatric patients
- terminally ill/medical conditions
134
Why is the elderly a growing number?
People living longer
Retaining natural teeth into old age
Heavily restored dentition
Medical conditions reduce mobility and self care
Increasing age increases risk of dementia
Xerostomia causing caries risk
135
Explainbthe careful triage indicated for domiciliary care patients?
Where possible treat patients in surgery
Eligibility criteria:
- can you get tonappoibtments
- do you have someone to accompany
- can you use a taxi
136
What are the limitations to treat for domiciliary care?
Reduced hygiene
Lack a clean workspace
Hand washing facilities
Procedures can be too complex in a non clinicalmenvriobeknt
Risk assessment of environment patient and specific clinical procedure is vital
137
Name the 6 categories for domiciliary dental care?
Location
Environment
Manual handling
Cross infection
Patient factors
Clinical procedures
138
Describe the 3 levels of clinical risk assessment for domiciliary care
L1 - exam, treatment plan preventative advice, OHI and dietary advice
L2 - scaling, Fl, provisional dressing, extraction of mobile, denture construction and review
L3 - do not treat on a domiciliary basis, advanced perio, intermediate or advanced resto or surgery
139
Main issues arising for elderly patients?
Oral hygiene maintenance
Root caries
140
What problems arise for a dentist during a domiciliary visit?
Preparation and equipment
Portable equipment
Clinical kit for denture work
Compact portable dental unit
Emergency kit
Waste management
141
Name the 3 most common cancers by gender?
Male:
- prostate
- lung
- colorectal
Female:
- breast
- lung
- colorectal
Breast cancer and lung cancers were the most common cancers worldwide contributing to 12.5% and 12.2% of the total new cases diagnosed in 2020. Colorectal was the third most common cancer contributing to 10.7% of new cases
142
Name the main forms of leukemias and lymphomas?
Acute Lymphoblastic Anaemia (ALL)
Acute Myeloid Leukaemia (AML)
Chronic Myeloid Leukaemia (CML)
Chronic Lymphocytic Leukaemia (CLL)
Non-Hodgkin Lymphoma
Hodgkin Lymphoma
Multiple Myeloma
The Chronic Myeloproliferative Diseases (biologically malignant)
143
Describe the treatment options for haematological malignancies?
Surgery
Radiotherapy - often in doses greater than 50 grays (Gy*7)
Chemotherapy
+/- hematopoietic stem cell transplantation (HSCT)
Immunotherapy – Targeted Therapy (TTs)
144
Describe the meaning of the following in regards to cancer treatment regimes?
Induction?
Snadwich?
Adjuvant?
Concurrent?
Palliative?
Indiction:
- before, to reduce size
Sandwich:
- between tretament, reduce metastases risk
Adjuvant:
- after, imprive disease free survival
Concurrent:
- with other, sensitive tumour cell
Palliative
- after other, shrink residual tumour and pain relief
145
What important dental adjuvant do breast cancer sufferes take?
Zoledronic acid with chemotherapy
146
What important drug is given to cancer sufferes that can affect them dentally?
corticosteroids
- worse if taken with bisphosphonates
147
Name 3 ankylating agents?
Busulphan, Chlorambucil, Cyclophosphamide
148
Name 2 cytotoaxic antibodies?
Bleomycin, Doxorubicin
149
Name 2 antimetabolities?
Flurouracil, Methotrexate
150
Name 2 vinca alkaloids?
Vinblastine, Vincristine
151
Name a platinum compound?
Cisplatin
152
Describe the targeted therapy nomenclature?
153
Name the 7 oral complications of chemotherpay?
Mucositis
ulceration
lip cracking
Infections – increased susceptibility bacterial/candidal/viral disease
Bleeding – spontaneous gingiva/mucosal bleeding, crusting of the lips
Dysgeusia – an alteration in taste or smell.
Orofacial Pain
154
Name the 3 consequences of chemotherapy on the blood? and when it presents?
Anaemia
Neutropenia
Thrombocytopenia
Present from commencement of cancer therapy until up to 4 weeks post therapy
155
Describe what is indcluded for basic oral care for a patient with cancer?
Prevention of Infection
Pain control
Maintain Oral functions
Managing the complications of the cancer treatment
Improve QoL of the patient
156
Gold standard healing time between doses of chemo or stem cell transplant?
10 days
extractions liase with oncologist
157
What must be undertaken by a dentist before the start of chemo/HSCT therapy?
Comprehensive dental clinical and radiographic oral investigation
Eliminate sources of infection – odontogenic and non-odontogenic
Definitive dental treatment plan
Address urgent dental needs - ideally allowing time for healing.
Supportive periodontal treatment – intensified oral hygiene to reduce the risk of infection and fever associated with oral conditions
Enhanced prevention
158
Name the 7 side effects of chemotherapy and what a denist can do to help?
159
1 year and 5 year survival rate for breast, prostate, skin, stomach, osephageal, lung, liver and pancreas comparison?
Cancer survival varies between types of cancer. One-year survival is above 95% for breast, prostate and skin cancer, but below 50% for stomach, oesophageal, lung, liver, and pancreatic cancer.
Five-year survival is above 85% for breast, prostate and skin cancers, but below 20% for oesophageal, lung, liver and pancreatic cancers.
