Special Care Flashcards
What is special care dentistry?
concerned with providing and enabling the delivery of oral care for people with an impairment or disability
What is the aim of special care dentistry?
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
Name the 3 groups who require special care dentistry (SCD)?
- 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 2. People who have a condition that has direct or indirect repercussions on their oral health 3. People who are disabled by their social, environmental or cultural context, which reflects on their oral health.
Is SCD continious or sporadic for pateints?
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
How are treatment plans devised for SCD patients?
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
Name the 4 principles of dentistry?
- 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
Total number of disabled patients in the UK?
Between 8.6 and 10.8 million people1/4 of us
Inequalities in SCD - Do they occur? How do they occur?
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.
Department of Health document detailing changes to dentistry which encompasses pateints with disabilities?
Valuing people’s oral health, a good practice guide for improving the oral health of disabled children and adults (2007)
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?
- 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
What’s wrong with the current NHS contract 2006, UDA system?
- 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.
What is the case-mix model?
allows objective assessment of the complexity of the provision of care for people with disability through a structured matrix.
Name the 6 criterion in which the case mix model is based upon?
- Ability to communicate 2. Ability to co-operate 3. Medical status 4. Oral risk factors 5. Access to oral care 6. Legal and ethical barriers
Name the type of factor considered for - Ability to communicate?
Need for interpreter or other means of communication; degree of learning disability or dementia
Name the type of factor considered for - Ability to co-operate
Additional appointment time or acclimatisation visits required; need to use sedation or GA
Name the type of factor considered for - Medical status
Treatment modification required; degree of impact of medical or psychiatric condition on the provision of care
Name the type of factor considered for - Oral risk factors
Ability to carry out oral hygiene; dietary conditions, eg PEG feeding, severe xerostomia
Name the type of factor considered for - Access to oral care
Support of carer required to get to the surgery; use of wheelchair recliner or hoist; need for domiciliary care
Name the type of factor considered for - Legal and ethical barriers
degree of capacity to consent; need to consult with other professionals or carers; need to hold best interest meeting or case conference
The Disability Discrimination Act 1995 - What did it include? update?
terms of alterations to buildings and surgeries and changes to service delivery which may be reasonably expected of the general dental practitioner2004
The Equality and Human Rights Commission 2007 - what did it include?
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.
The Disability Equality Duty 2006 - what did it include? name the 4 main categories?
It requires that any public body (including service providers) needs to look actively at ways of ensuring that disabled people are treated equallynsuring 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.
How to adapt practice to improve access to the building?
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.
How to adapt practice to improve access to the dental surgery?
practice of ongoing and documented disability awareness training for all staff1. 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.
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 attachmentsAs 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 helpWhen transfer is not straightforward, because the patient cannot stand or weight bear, ‘transfer’ or ‘banana boards’ can be usedA hoist is the best option for safe and efficient transfer of patients unable to do so independently, to the dental chairThe 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
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 bitterssturdier instrumentsempathy for extreme gaggers
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
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
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
What factors can aid the SEAMLESS network?
Prevention to patient• Carer training (Caring for Smiles, Open Wide)• Undergraduate, Postgraduate, Continuing ProfessionalDevelopment• NEBDN Certificate in Special Care Dental Nursing• Training for the dental team - Medical emergencies - Manual handlingMultidisciplinary Working• Development of networks with other health and social careprofessionals• Sharing of information• Eases anxiety if the correct information can be sought quickly• i.e how to access emergency care
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
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 specialisedservices• Shared care model between GDS and Special Care Dentistry• Multi-agency working
Act relating to consent?
Adults with Incapacity (Scotland) Act (2000)
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
What is the definition of in/capacity?
AWI defines capacity as when a person is incapable of:1. Acting2. Making decisions3. Communicating decisions4. Understanding decisions5. Retaining the memory of decisions
How can capacity be affected?
Capacity may be diminished temporarily or permanently, partially ortotally• Remember – the law in Scotland presumes all adults 16 years and olderhave sufficient capacity to decide on their own medical treatment
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)
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
Name the 5 principles of AWI?
- Any action taken on behalf of the person must benefit the person2. Any action must be the least restrictive option that will achieve the desired effect3. Before making a decision on behalf of a person, account should be taken of the person’s past and present views and preferences4. 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 person5. 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.
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 experientialbackground• Is not under the influence from a relative, carer or other third party
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
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
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
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
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
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
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
AWI flowchart?
look at it
What must a patient hold to prove Incapacity?
Adult with Incapacity Certficate
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
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
What to do during an AWI emergency? Only Scotland
Identify whether the situation is an emergency? YesOver 16? YesDo they have capacity? NoDo they have a welfare guardian? Yes, contact themIf non-contactable, must try and relieve pain, but is mainly reversible
3 emergencies of dentistry?
HaemorrhageFacial SwellingTrauma
What happens if 2 welfare guardians can’t agree?
Must get a second opinionMust find a consensus for the treatment
Welfare guardian vs PoA? Differences
Welfare guardian - patient has never had capacityPoA - patient have had capacity in the last
What is the defintion of cerebral palsy?
Wide spectrum of non progressive neurological and physical disabilitiesDevelopmental or as a result of peri natal insult suxh as hypoxia, trauma or infection
Name the 3 types of cerebral palsy?
SpasticAtaxic Dyskinetic
Describe spastic cerebral palsy?
Muscles appear stiff and tightArises from motor cortex damageMost common
Describe dyskinetic cerebral palsy?
Involuntary movementsArises from basal ganglia damage
Describe ataxic cerebral palsy?
Shaky movements. Affexts balance and sense of positioning in spaceCerebellum damage
Name the 4 types of coverage for cerebral palsy?
MonoplegiaHemiplegiaParaplegiaQuadraplegia
What are the dental features for a patient with cerebral palsy?
Higher level of untreated diseaseDevelolmebtsl abnormalitiesMalocclusionUncontrolled movementsBruxismDroolingPeriodontal diseaseCaroes
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 issuesAffafts both motor and sensory transmissionRelapsing or progressive Weatern20-40More women
Neurological symptoms of multiple sclerosis?
Visions problems Numbness or weaknessFacial pain or trigeminal neuralgiaSpeech, swallowing and hering problemsSpasticity, spasms and tremorFatigueDepression
Dentalnmanagement for a patient with MS?
Shorter appointments- their best tineRigours prevent Wheelchair accessDysphagia controlCannabis use?Dizzy and vertigo control
What is the defintion of Huntington disease?
Inherited progressive degenerative neurological disorderAutosomal dominant 30-50Death 15-20 years after onsetPneumonia the killer
Name the physical symptoms of HD?
Uncontrollable muscular movement- stumble and clumsyChorea
Name the cognitive symptoms for HD?
Lack of concentrationShort term memory lapsesLack of interest and organisation skills
Name the psychological symptoms for HD?
DepressionMood swingsFrustration Loss of flexibility
How to manage HD dentally?
Preventative regime Dietician discussionMore basic treatmentIV conscious sedationTrauma to lip die to choroid movement Check consentRespect wishes
Patients that need addition help for oral care?
MSArthriticStrokeCerebral palsy
Name 3 diseases that effect periodontal health?
Medications suxh as antiepileptic DiabetesCardiac disease
Things that will make dentistry harder to SCD?
Dento facial anomaliesOpen kip postureMouth breakingShort roots and crownsSevere early onset perio diseaseImpaired inflammatory response
Name 3 medically induced gingival hyperplasia?
Phenytoin - antieplilepticCa ch blocker - nifidipineCiclospirin - transplant drug
Describe gingival hyperplasia?
Pink and firmDon’t bleed easily Treat with education, OHI and scalinf
How is the oral micoobiome affected by tube fed patients?
Reduction in oral stimulus and changes in saliva constituentsCalculus build upCarer educationAspiration risk
How to control plaque for a SCD patient?
Education Adaptations to toothbrushChlorhexidine myFrequent scaling
Describe an enhanced prevention plan for oral hygiene for a SCD?
OHIHigher fluoride toothpasteMore frequent recallEducationEmpower the patient
Name the 4 doee programmes for education in SCD?
Caring for smiles - dependent elderlyOpen wide- 16-64 with additional needsMouth Matters - prisonersSmile4Life - homeless
What help do people with learning disabilities need?
o Understand new or complex information.o Learn new skillso Cope independently
Ratio of people with LD across 2000?
40 mild or moderate8 will be severe or profound
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)
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
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
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
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
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
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
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
WHat are the top tips for communcation with a patient having a LD?
Speak slowly and as clear as possible2. Find a good place to communicate in, lessen distractions3. Check with the person that you understand what they are saying4. If the person wants to show you something – go with them5. Watch the person (non verbal cues)6. Keep communication simple use key wordBeware of literal interpretation8. Learn from experience, ask carers for help9. 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
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.
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)
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.
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
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
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 biologyDiagnostic manuals –l ists of conditions and their features provide criteria for diagnosis (ICD-10, DSM-5) – “operationalized”
Describe the aetiology of mental disorders?
Multifactorial – genetic and environmental (abuse/neglect/trauma) risk factorsDisorders can - overlap (e.g. Neurodevelopmental Disorders)- evolve (Bipolar Disorder)Disorders may be final common pathways- Depression (familial v life-events)- SchizophreniaOverlap with normal experience - e.g. depression, anxiety
How to take a good history to garner information on mental disorders?
History of Presenting ComplaintSocial HistoryFamily HistoryPast Medical History – esp. illness which may mimic psychiatric illness e.g. hypothyroidismPast Psychiatric History – admissions, treatments, complicationsPersonal History – Birth, childhood, school, work, relationships, forensic history
Describe the categopries included for a mental state examination?
Appearance and Behaviour – attire, self-care, agitationSpeech – rate/rhythm/volumeThought Form e.g. tangential, concrete, flight-of-ideasThought Content e.g. preoccupations, delusionsMood e.g depressed, euthymicPerception (sensory) e.g. illusions, hallucinationsInsight – patient’s view of their symptomsCognition i.e. orientation, memory, language, visuospatial abilities (construction), abstract reasoning, executive functioning
Name the simple invesitagations that may give reason to mental disorder?
Depression – TFT, FBC, glucoseDementia – FBC, U&E, LFT, TFT, B12&Folate, glucoseNeuroimaging (CT/MRI)
Describe the possible bioloigcal treatment for mental disorders?
Antidepressants (5HT,NA); Antipsychotics (DA); Mood stabilizers; Sedatives; Dementia drugsSome may have significant side-effects, esp. if used long-term
Describe the possible psychological treatment for mental disorders?
e.g. Cognitive Behavioural Therapy (CBT), Psychodynamic psychotherapy, CounsellingNot free from adverse effects
Describe the possible social treatment for mental disorders?
e.g. exercise, groups, employment, “wellbeing” interventions
What is the definition of capacity?
Capacity is ability to make reasoned decisions about finances and welfare (includes medical & dental Rx)Capacity is assumedSometimes worth questioning if mental illness is likely interfering with capacity to consent to treatment
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
Describe psychosis - specific features and causes?
Loss of contact with realitySpecific features:- Delusions (fixed false beliefs)- Hallucinations (false perceptions)- Disordered thought-form (thinking-patterns)Not a specific illnessCauses:- Mood disorders, schizophrenia, organic conditions
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 behaviourNegative” symptoms – DA underactivity- Lack of thoughts, absence of emotion, lack of drive, social and occupational difficultiesCause disabilityTreatments- Antipsychotics – DA blockers – for positive symptoms- Rehabilitation (non-medical interventions) if negative symptoms causing ongoing disability
Give a description of dementia? - prevalence? positive symptoms? negative symptoms? treatment?
Not a normal part of ageing i.e. not normal age-related memory declineCognitive decline (not just memory)Functional declineBPSD (Behavioural and Psychological Symptoms of Dementia) e.g. anxiety, depression, hallucinations, unusual preoccupations, repetitive behaviourProgressiveTypes - Alzheimer’s, Vascular, Lewy Body Dementia, Fronto-Temporal DementiaDecreased Acetyl-Choline functioningTreatment- Exclude reversible causes- Medication for Alzheimers e.g. Donepezil, Galantamine, Rivastigmine, Memantine- Social Care
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/hypoactiveOften fatal (up to 40%)Not an illness in itselfCaused by an underlying organic condition e.g. infection, metabolic disturbance, drug withdrawal, head injuryOften occurs in the elderly due to pre-existing poor cholinergic (acetyl choline) functionTreatment:- Investigate and treat underlying cause- Good nursing- Sedation if necessary – using antipsychotics - not Benzodiazepines (BZs) in the elderly- Delrium Tremens (“The DTs”) - BZs
Give a description of depression? - prevalence? positive symptoms? negative symptoms? treatment?
Not just unhappinessSyndromeCore features; low mood, limited enjoyment, low energyOther symptoms; poor sleep, poor appetite, poor concentration, tearfulness, low libido, negative thoughts, suicidal thoughtsThought to be associated with Serotonin (5HT) and Noradrenaline (NA) underactivityCauses – (there isn’t always a “reason” for depression)- Psychological- Social - BiologicalComplications- psychosis- suicide- social and occupational problems e.g. loss of job or relationship- chronicityTreatment- Mild – Psychological treatments (usually based around CBT, can be using books, online or by telephone)- Moderate, Severe – Medications, Electro-Convulsive Therapy (ECT)
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, TryptophanTricyclic antidepressants – lethal in overdose, uncommonly prescribedMonoamine 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.
Give a description of bipolar affective disorder? - prevalence? positive symptoms? negative symptoms? treatment?
“Manic depression”Alternating episodes of depressed and elevated (“mania”) moodEpisodes are syndromalCore feature; elevated or irritable moodAssociated features; - over-talkative, over-sociable, increased energy, grandiose schemes, subjectively clear and rapid thinking, over-spending, promiscuity, risk-takingDelusions and hallucinations if psychoticGenerally avoid antidepressantsMood stabilizers - Lithium - NSAIDs toxicity- metronidazole toxicity- Valproate, Carbamazapine- LamotrigineAntipsychotics e.g. Quetiapine
Describe anorexia?
Abnormal body imageFood restriction and other behaviours to reduce weightLow body weight (BMI < 17.5)Sexual- Amenorrhoea/sexual dysfunction- If onset prepubertal, failure to develop secondary sexual characteristics
Describe bulimia?
Binge eating/ preoccupation with foodBehaviours to reverse weight-gain - Including but not limited to self-induced vomiting“Morbid dread of fatness”
Describe the presentation of eating disorders at the dentist?
May first present to dentistsSigns- Russell’s sign - Erosion of dental enamel- Erythema of mucosa - Periodontitis- Salivary hypofunctionMay result in death
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 intakeTreatments- Re-establish nutrition- Psychological therapies- SSRIs (bulimia)
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
Describe the features, signs for alcohol dependence syndrome?
Features- compulsion, salience, tolerance, loss of control, continued use despite evidence of harm, withdrawalsPhysical signs- Flushed complexion, coarsening of facial features, sweating palms- Stigmata of liver disease such as finger clubbing, jaundice, bruising, ascitesBlood tests- Raised MCV (FBC)- Raised GGT (LFT)Treatment – detoxification, then drug and non-medical interventions to support abstinence
Describe the complications of alcohol dependence?
Acute intoxication - injuryWithdrawal can be fatal- DTs- Convulsions- Sudden cardiac deathSocial and occupational problemsPhysical health problemsPsychiatric complications- Depressive symptoms, memory problems
Describe the categories, symtpoms and tretament for anxiety disorder?
Categories- Specific phobias – fear of the dentist- Generalized anxiety disorder- Panic disorderSymptoms- Emotion (“anxiety”, fear)- Thoughts (worries)- Physical symptoms (e.g. palpitations)Treatments- CBT- SSRIs
Describe peronality disorder?
Deeply-ingrained maladaptive patterns of behaviour which cause distress for the individual or for society around themExtreme 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
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 realityPsychotherapy (various modalities and “tiers”) Medications may have some limited benefit
Describe the oral findings for a patient with schizophrenia
Poor OHHigh caries ratePeriodontal disease commonDecreased saliva flow (long term neuroleptics)Tardiness dyskenesia Acutw dystopia (facial grimacing, tongue protrusion and neck stiffness)Delusional oral symtpms
Describe the dental aspects for a schizophrenic patient?
Impaired gag reflex - protect airwayApproach slowly and non-threatening manner - explain what to expectBe open - speak normal volume - paranoiaNo elective treatmentsSedatives used with caution - synergistic with neuroleptics Shorter appsCare with smoking cessation - clozapinw lead to toxicity
What are the oral findings for a patient with depression?
Dry mouth- due to meds (antidepnor lithium)- oral candidosis- increased caries riskFacial dyskinesias- occasional side effects of monoamine oxidase inhibitor - invol move of mouth, lips or tongueAtypical facial painBurning mouth Sore tongueTMJ pain dysfunction syndrome
What are the dental aspects of a patient with depression?
Use tact, patience and sympathyOH neglectTricyclic and MAOIs can cause postural hypotensionMAOIs make GA a risk due to prolonged resp depression, also dangerous with many analgesics
What are the dental aspects for a patient with bipolar disorder?
Manic disorderMania - period of elevated moodDepression - period of low moodDifficult to manageLithium cause dry mouthNSAIDs, metronidazole, tetracycline induce lithium toxicity
Name 4 psychiatric illness with dental signs?
Eating disorderHypocondriasisPsychogenic painSubstance misuse
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 vomitingXerostomia
Explain how to manage a patient with an eating disorder?
Poor compliance and associated behavioural problemsUse pain from enamel erosion as reason not to eatGA/Sedation may not be safe due to medical problems Rising with bicarb after vomiting may reduce the damage to teethTopical fluoride to reduce sensitivity
Why is domiciliary dental care necessary?
Legislation to protect vulnerable members of society from discrimination - Equality Act 2010Dentists must take reasonable steps to allow access to dental care
Domiciliary care GDC standard?
1.6.3- you must consider patients disabilities
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
Why is the elderly a growing number?
People living longerRetaining natural teeth into old ageHeavily restored dentitionMedical conditions reduce mobility and self careIncreasing age increases risk of dementiaXerostomia causing caries risk
Explainbthe careful triage indicated for domiciliary care patients?
Where possible treat patients in surgeryEligibility criteria:- can you get tonappoibtments- do you have someone to accompany- can you use a taxi
What are the limitations to treat for domiciliary care?
Reduced hygieneLack a clean workspaceHand washing facilitiesProcedures can be too complex in a non clinicalmenvriobekntRisk assessment of environment patient and specific clinical procedure is vital
Name the 6 categories for domiciliary dental care?
LocationEnvironmentManual handlingCross infectionPatient factorsClinical procedures
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 reviewL3 - do not treat on a domiciliary basis, advanced perio, intermediate or advanced resto or surgery
Main issues arising for elderly patients?
Oral hygiene maintenanceRoot caries
What problems arise for a dentist during a domiciliary visit?
Preparation and equipmentPortable equipment Clinical kit for denture workCompact portable dental unit Emergency kitWaste management
Name the 3 most common cancers by gender?
Male:- prostate- lung- colorectalFemale:- breast- lung- colorectalBreast 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
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 LymphomaHodgkin LymphomaMultiple MyelomaThe Chronic Myeloproliferative Diseases (biologically malignant)
Describe the treatment options for haematological malignancies?
SurgeryRadiotherapy - often in doses greater than 50 grays (Gy*7) Chemotherapy +/- hematopoietic stem cell transplantation (HSCT)Immunotherapy – Targeted Therapy (TTs)
Describe the meaning of the following in regards to cancer treatment regimes?Induction?Snadwich?Adjuvant?Concurrent?Palliative?
Indiction:- before, to reduce sizeSandwich: - between tretament, reduce metastases riskAdjuvant:- after, imprive disease free survivalConcurrent:- with other, sensitive tumour cellPalliative- after other, shrink residual tumour and pain relief
What important dental adjuvant do breast cancer sufferes take?
Zoledronic acid with chemotherapy
What important drug is given to cancer sufferes that can affect them dentally?
corticosteroids- worse if taken with bisphosphonates
Name 3 ankylating agents?
Busulphan, Chlorambucil, Cyclophosphamide
Name 2 cytotoaxic antibodies?
Bleomycin, Doxorubicin
Name 2 antimetabolities?
Flurouracil, Methotrexate
Name 2 vinca alkaloids?
Vinblastine, Vincristine
Name a platinum compound?
Cisplatin
Name the 7 oral complications of chemotherpay?
Mucositisulcerationlip crackingInfections – increased susceptibility bacterial/candidal/viral diseaseBleeding – spontaneous gingiva/mucosal bleeding, crusting of the lipsDysgeusia – an alteration in taste or smell.Orofacial Pain
Name the 3 consequences of chemotherapy on the blood? and when it presents?
AnaemiaNeutropeniaThrombocytopeniaPresent from commencement of cancer therapy until up to 4 weeks post therapy
Describe what is indcluded for basic oral care for a patient with cancer?
Prevention of InfectionPain controlMaintain Oral functionsManaging the complications of the cancer treatmentImprove QoL of the patient
Gold standard healing time between doses of chemo or stem cell transplant?
10 daysextractions liase with oncologist
What must be undertaken by a dentist before the start of chemo/HSCT therapy?
Comprehensive dental clinical and radiographic oral investigationEliminate sources of infection – odontogenic and non-odontogenicDefinitive dental treatment planAddress 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 conditionsEnhanced prevention
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.
