Special Care Flashcards
Define, learning disability.
A significantly reduced ability to understand new or complex information, learn new skills and cope independently
What are associated clinical features of a an individual with a learning disability?
- epilepsy
- visual defects
- hearing and speech disorders
- facial deformities
- body-rocking and self-mutilation
- feeding difficulties
What are the 8 associated health conditions a person with Down syndrome may suffer from?
- Cardiac problems
- Spinal problems
- Malignant disease
- Dementia
- Immune disease
- Hearing loss
- Visual defects
- Seizures
What are common oral findings in autistic patients?
- Bruxism
- Traumatic lesions
- Poor oral hygiene
- Preference for sweet foods (higher caries risk)
What act of UK parliament states that it is against the law to discriminate against someone because of age, disability, gender reassignment, Marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, or sexual orientation.
Equality Act 2010
What is domiciliary dental care?
Providing dental treatment out with dental clinics for patients whose personal circumstances makes it infeasible to attend a dental clinic.
What type of dementia is most common in women?
Alzheimer’s disease
What type of dementia is most common in men?
Vascular dementia
What are the medical risk factors for dementia?
- type 2 diabetes
- hypertension
- high cholesterol
- obesity
- depression
What are the lifestyle factors for dementia?
- physical inactivity
- smoking
- unhealthy diet
- excessive alcohol
What specific form of dementia usually occurs in individuals who have experienced head injuries playing sports?
Chronic traumatic encephalopathy
What are the 5 types of dementia?
- Alzheimer’s disease
- Vascular
- Mixed
- Lewy body
- Fronto temporal
What are the main clinical features of Alzheimer’s disease?
- Short-term memory loss and word-finding difficulties
- confusion
- mood swings and frustration
- withdrawn
What is the association between periodontal disease and Alzheimer’s?
Evidence that pathogens from periodontal disease and/or their virulence factors are able to enter the brain via vascular and neural pathways.
What causes vascular dementia?
Reduced blood flow to the brain
What is lewy-body dementia?
Where, Lewy bodies, small deposits of protein in nerve cells, cause problems with thinking, movement, behaviour and mood.
What are the features of lewy-body dementia?
- Unpredictable changes in attention and alertness
- visual hallucinations
- disturbed sleep
- associated with Parkinson’s disease
What type of dementia generally affects people of slightly younger age (e.g. 40/50 years old)?
Fronto-temporal dementia
What are the key features of fronto-temporal dementia?
- personality change
- challenging behaviour/sexually inappropriate behaviour
- short temperedness/aggression
- mood swings
What drug, approved in the UK, is the first drug to convincingly slow progression of early stage Alzheimer’s disease?
Lecanemab
Why might a GA be contraindicated for a patient with dementia if there are other suitable options?
As there is evidence to suggest that dementia can worse following a GA
Prior to dental procedures, what would a patient with a platelet disorder require?
A full blood count
What is von willebrand disease?
Inherited bleeding disorder where there is deficiency in von willebrand factor, an essential co-factor for normal platelet adhesion.
What is more common, haemophilia A or B?
More common: Haemophilia A (1/5000 live male births)
Haemophilia B (1/20000 live male births)
For what dental procedures is haemostatic cover therapy required for someone with an inherited blood disorder?
- Extractions
- Oral surgery
- Periodontal surgery
- Implant surgery
- Inferior dental blocks
- Lingual infiltrations
For what dental procedures is haemostatic cover therapy NOT required?
- Buccal infiltration
- Palatal infiltration
- Intraligamentary injection
- Intrapapillary injection
For dental extractions, what 4 measures should be in place if a patient has an inherited bleeding disorder?
- Liase with haemophilia centre to organise factor replacement therapy
- Use of buccal articiane
- Tranexamic acid mouthwash and/or tablets
- Topical haemostatic agents- e.g. pressure packs, sutures, oxidised cellulose, fibrin glue.
Name 3 dental aspects of myeloma.
- Root resorption
- Loose teeth
- Mental anaesthesia
Name 4 dental aspects of leukaemia.
- Mucosal pallor
- Ulceration
- Gingival swelling
- Spontaneous bleeding
Define MRONJ.
“Exposed bone in the maxilla or mandible that has persisted for more than 8 weeks in patients taking anti-resorptive or anti-angiotensin drugs and where there is no history of radiation or no obvious metastatic disease to the jaws”
What are key symptoms of MRONJ?
- Delayed healing
- Can be spontaneous without trauma
- Pain
- Soft tissue infection/swelling
- Numbness
- Exposed bone (not always)
Which drugs will put a patient at higher risk of developing MRONJ?
- Bisphosphonates
- RANKL inhibitors
- Anti-angiogenic drugs
What is the action of Bisphosphonates?
“Drugs that reduce bone resorption by hindering the formation, recruitment and function of osteoclasts.”
According to the Adults with incapacity Act 2000, what does incapacity mean?
Incapable of:
1. Acting
2. Making a decision
3. Communicating a decision
4. Understanding a decision
5. Retaining memory of a decision
What is the important pneumonic used to assess capacity?
AMCUR
What 4 ways can you check that a patient has understood and has the capacity to consent?
- Open questions
- ‘Chunk and check’
- ‘Teach back’
- ‘Taking the blame’
What should be issued if a patient is deemed to lack capacity to consent to dental treatment?
Section 47 certificate
According to what 5 key principles from AWI is section 47 certificate issued?
- BENEFIT
- Least restrictive of freedom
- The persons past and present wishes should be taken into account
- Consult relevant others
- Encourage residual capacity
What is a proxy?
Legally recognised individual who has been authorised to act on behalf of an adult with incapacity
What is a power of attorney?
An individual who has been chosen to act on another individuals behalf (should the need arise). This individual is granted power of attorney by the adult in question whilst they have capacity.
What are the three types of power of attorney?
- Welfare
- Continuing (money,property,business)
- Joint or combined
When checking PoA documents regarding power to consent on behalf of another individual, what sentence MUST you see in writing to confirm power to consent for dental treatment?
“The power to consent or withhold consent to medical and dental treatment”
How is an individual granted as a “Gaurdian”?
When an adult either:
1. No longer has capacity to choose who they wish to make decisions for them
OR
2. The adult has never been able to make their own decisions
Who grants someone a Gaurdian?
Court process, granted by a Sheriff.
Does being appointed a guardian have an expiry date?
Yes, usually appointed for 3 years.
What is an intervener?
An individual appointed for a one off event to consent on behalf of another individual who lacks capacity.
Who would you contact to check proxy status?
Office of the Public Guardian
Who is able to complete an AWI certificate?
- Doctors
- Health professional who have successfully completed relevant training in the assessment of capacity including dental practitioners, opticians and registered nurses.
What are the 5 main functions of the renal system?
- Excretion of waste products
- Maintaining fluid and electrolyte balance
- Acid-base balance
- Secretion of hormones (renin, erythropoietin, activate Vit D)
- Excretion of drugs
When does acute renal failure tend to present?
After surgery or severe injury when renal blood vessels become obstructed
Define, kidney damage, or a reduction in glomerular filtration rate (GTR) for 3 or more months.
Chronic kidney disease
What are the three most common causes of chronic kidney disease?
- Diabetes
- Hypertension
- Glomerulonephritis
What investigations are required to diagnose chronic kidney disease?
- Blood test for kidney function
- Urine test to assess kidney damage
What are the 5 stages of chronic kidney disease?
- Early CKD
- Mild CKD
- Moderately severe
- Severe CKD
- End stage renal failure
What do these clinical features suggest?
- Depression, lethargy
- Nausea, vomiting, anorexia
- Weakness/fatigue
- Peptic ulceration
- Bruising
- Diarrhoea
- Bone pain
Renal failure
Name 9 oral findings of Chronic kidney disease.
- osseous lesions
- xerostomia
- metallic taste
- halitosis
- accelerated calculus production
- pale oral mucosa
- oedema
- oral ulceration
- parasthesia
What is a patient with CKD more at risk of, which it’s important to consider in their dental management?
Bleeding and infection
What substances should someone with CKD be limiting in their diet and why?
- Salt and potassium - control blood pressure
- Phosphorus - pulls calcium from bones
- Potassium- causes heart problems
What are the two types of renal dialysis?
- Haemodyalsis
- Peritoneal dialysis
What type of renal dialysis is performed in health centres/hospitals, requires arterio-venous access, removes excess fluid and uraemic solutes and ensures that a patient is heparinised?
Haemodyalsis
Why is it essential for patients on haemodialysis to be heparinised?
To thin the blood so to prevent clots from forming in the fistula
How many times a week is haemodyalsis required and for how long?
3 times a week for 4 hours
What type of renal dialysis is performed at home by patient or carer, where a catheter is placed in the peritoneal cavity and dialysis is exchanged at regular intervals?
Peritoneal dialysis
If a patient is on renal dialysis what is important to do as their dentist before treatment?
Consider risk of bleeding, infection and drug interactions.
Consult their renal physician
When is the best time for dental treatment for a patient on renal dialysis?
The day after haemodialysis
What does a renal dialysis patient require prior to extraction?
FBC and coagulation screening
What drugs should be avoided in patients on renal dialysis?
Aspirin and other NSAIDs
What dental treatment is important to consider undertaking prior to renal transplant?
- extract teeth of poor prognosis and eradicate sources of potential infection
- address any decay/calculus
- put patient on preventative regime
What dental conditions is a patient who has had a renal transplant more at risk of developing?
- Gingival hyperplasia
- Oral tumours
- Candidiasis
- Herpes simplex virus
What are three adjunctive cancer treatments?
- Radiotherapy
- Chemotherapy
- Chemo-radiotherapy
How does radiotherapy work in the treatment of cancer?
Uses ionising radiation to kill DNA of cancer cells
Why are radiotherapy and chemotherapy considered “blunt tools”?
Because they not only wipe out cancer cells but also other normal healthy body cells
Why is xerostomia a common radiation induced complication post radiotherapy?
Because salivary glands are very sensitive to radiotherapy and easily affected by this treatment causing reduced amount and quality of saliva to be produced.
What are the three types of radiotherapy?
- Conventional
- IMRT
- Rapid arc
How long does radiotherapy treatment last for?
6 weeks
What are the GENERAL side effects of radiotherapy?
Potential exam Qu**
- Fatigue
- Nausea
- Burns
- Pain
What are the ORAL side effects of radiotherapy?
Potential exam Qu**
- Mucositis
- Xerostomia
- Radiation caries
- Periodontal disease
- Dysgeusia (altered taste)/aguesia (total loss of taste)
- Trismus
- ORN
What might patients describe mucositis as feeling like?
“Sunburn in their mouth”
How does radiation caries typically present?
As generalised, active, cervical caries in a circumferential pattern.
When restoring cavities due to radiation, what are the 4 things you must warn the patient of?
- The caries may recur
- The caries is aggressive
- This type of cares is difficult to treat/manage
- There is a chance that the crown will fracture off at some point in the future
True or false?
You can get ORN in oral cavity if you have had radiotherapy to any part of the body.
False. Can only occur if you’ve had head and neck radiotherapy.
What 8 dental interventions can dentists implement for a patient prior to radiotherapy?
- Extraction of hopeless teeth
- Duraphat toothpaste and varnish
- Fluoride trays
- Hygiene phase therapy
- Therabite
- Pharmaceuticals
- Low level laser therapy (LLLT)
- Take impressions early to avoid difficulties if trismus occurs after radiotherapy
What is the criteria for considering a tooth to be of “hopeless” prognosis?
- Gross caries
- Mobile (grade 2 or >)
- Pockets >5mm or more
- PA pathology
- Furcation involvement
What is the significance in hygiene phase therapy for patients prior to radiotherapy?
It may lessen severity of mucositis post treatment
What does therabite treat?
Trismus
If you believe a patient is at risk of ORN, what should be considered prior to any treatment?
Antibiotic prophylaxis
How does chemotherapy work?
Drugs used to kill rapidly dividing cells, interferes with mitosis, apoptosis and tumour cell DNA.
What are the general side effects of chemotherapy?
- Fatigue
- Nausea
- Vomiting and diarrhoea
- Skin rash
- Hair loss
- Thrombocytopenia
- Neutropenia
Why is thrombocytopenia a concerning side effect of chemotherapy in regards to dental treatment?
Low platelets are a problem as the patient is more likely to have bleeding problems during treatment.
Why is neutropenia a concerning side effect of chemotherapy in regards to dental treatment?
Low neutrophils means patient is at higher risk of infection after treatment
What are 4 oral side effects of chemotherapy?
- Mucositis
- Infection
- Bleeding
- Temporary xerostomia
What can we prescribe to cancer patients to manage their mucositis?
- soft splints
- caphosol (mouthwash)
- LLLT
- HPT before chemo starts
Define, the physiological reaction to actual threat/danger?
Fear
Define, the physiological reaction to perceived threat/danger?
Anxiety
Define, a persistent and excessive fear of an object or situation that is not in fact dangerous.
Phobia
What is classical conditioning?
An automatic, conditioned response that is paired with a particular stimulus.
What does MDAS stand for and describe how the scale works?
- modified dental anxiety scale
Scores range from a minimum of 5 up to a maximum of 25.
- 5-9 no anxiety/low anxiety
- 10-18 moderate anxiety
- 19 or above significant dental anxiety/phobia
Give three examples of coping strategies for anxiety?
- Deep breathing
- Progressive muscular relaxation (PMR)
- Grounding
What is the applied tension method and how is it useful for a patient with a needle phobia?
It is a method where muscles in arms, legs and torso are tensed for 10-15 seconds at a time, this helps to prevent drop in blood pressure, reducing risk of patient fainting.
Define, “any congenital structural defect of the heart or adjacent great vessels”
Congenital cardiac condition
What is meant by a “cyanotic” congenital heart condition? and give an example.
“Any congenital heart defect that occurs due to deoxygenated blood bypassing the lungs and entering the systemic circulation”
Example = tetralogy of Fallot (group of structural abnormalities within the heart that occur together)
What is meant by a “acyanotic” congenital heart condition? and give an example.
Congenital heart defect where blood is shunted from left to right side of heart, most often due to a structural defect in the interventricular septum. Normal levels of oxyhaemaglobin in systemic circulation.
Example= ventricular septal defect
Name 6 oral findings you might expect to see in an individual with a congenital heart defect.
- Delayed eruption of both dentitions
- Increased positional abnormalities
- Enamel hypoplasia
- Vasodilation of pulp
- Increased periodontal disease
- Increased caries
What 6 dental considerations need to be given to individuals with a congenital heart defect?
- Bleeding tendency
- Are they taking anticoagulants?
- There is a risk of Infective endocarditis so consider antibiotic cover
- This patient may experience hypertension with LA containing adrenaline.
- This patient may experience hypertension associated with the dental tx/environment
- Are there associated issues such as cleft palate etc.
Identify the three conditions which the SDCEP have categorised as a sub-group requiring special consideration for antibiotic prophylaxis.
- Prosthetic valve repair
- Previous infective endocarditis
- Congenital heart disease (any type of cyanotic CHD and any type of CHD repaired with a prosthetic material)
If a patient is considered to need special consideration for antibiotic prophylaxis prior to dental tx due to a cardiac condition, what is the first thing you should do as the dentist?
Contact the patients cardiology consultant, cardiac surgeon or local cardiology centre for advice regarding if this patient requires antibiotic prophylaxis.
Define, “ the result of progressive myocardial ischaemia due to persistently reduced coronary blood flow.”
Ischaemic heart disease (IHD)
What is the cause of ischaemic heart disease?
Atherosclerosis and hypertension
What two drug types used to manage IHD may cause lichenoid reaction as an oral adverse effect?
- ACE inhibitors
- Alpha and beta blockers
What drug type used to manage IHD may cause gingival swelling as an oral adverse effect?
Calcium channel blockers (e.g. Amlodipine)
What drug type used to manage IHD may cause angioedema as an oral adverse effect?
ACE inhibitors
What drug types used to manage IHD may cause mucosal ulceration as an oral adverse effect?
- Beta blockers
- Potassium channel activators (e.g. Nicorandil)
If your patient reports they have unstable angina and requires dental treatment, where should this be carried out?
Recommended that unstable angina patients be treated in an acute hospital setting
How long must you wait to treat a patient after MI?
At least 6 months
Define, “BP consistently over 140/90mmHg”
Hypertension
What cardiovascular drug type has a potential interaction with adrenaline containing LA?
Beta blockers
Define, “a group of conditions that affect the structure of the heart muscle and its ability to pump blood around the body”
Cardiomyopathy
What 5 cardiac conditions put a patient at increased risk of IE according to SDCEP?
- Acquired valvular heart disease with stenosis or regurgitation
- Hypertrophic cardiomyopathy
- Previous infective endocarditis
- Structural congenital heart disease (excluding isolated atrial septal defects or fully repaired ventricular defects)
- Valve replacement
What type of heart condition at present, absolutely requires antibiotic cover before invasive dental treatment?
Any type of prosthetic valve or valve repair condition
