Special care Flashcards
- Protects adults at RISK OF HARM
What is harm?
- Harm can take many forms.
where is the most common place for harm to occur?
In the victim’s home.
What act prevents the discrimination of someone based on their age, sex, disability etc?
Equality act 2010.
How does the Equality Act 2010 define disability (2)?
A person has a disability if:
- The have a PHYSICAL or MENTAL impairment.
- The impairment has substantial and long term effect on their ABILITY TO PERFORM NORMAL DAY TO DAY ACTIVITIES.
6 most common impairements?
- Mobility 49%.
- Stamina/breathing/fatigue 37%.
- Dexterity 26%.
- Mental health 25%.
- Hearing.
- Vision.
What percent of the UK population is disabled?
19% (11.9 million).
- 6% children.
- 16% working adults.
- 45% over pension age.
- F > M
What % of people are born with disability?
- Only 17%.
Define physical disability?
Any condition that PERMANENTLY prevents NORMAL BODY MOVEMENT and/or CONTROL.
6 causes of physical disabilities?
- Inherited or genetic disorders.
- Conditions present at birth.
- Serious illnesses affecting brain, nerve or muscles.
- Spinal cord injury.
- Brain injury.
- Accidents.
Name 2 inherited conditions that can cause physical disability?
- Osteogenesis imperfecta.
- Huntington’s disease.
6 potential clinical appearances of a patient with osteogenesis imperfecta?
- Increased bone fractures.
- Collagen defects.
- SHORT stature.
- Hearing loss.
- BLUE sclera.
- DENTINOGENESIS IMPERFECTA (sometimes associated).
How common is osteogenesis imperfecta? How is it inherited?
- 1/15000 people
- Autosomal dominant or recessive.
What condition may osteogenesis imperfecta be associated with? How does this present (6)?
- DENTINOGENESIS IMPERFECTA.
- Discoloured teeth (blue/grey or yellow/brown).
- Translucent
- Weaker teeth.
- Bulbous crowns.
- Pulp chamber obliteration.
- Reduced root length.
How prevalent is Huntington’s disease? How is it inherited?
- 5-10 cases per 100,000.
- Autosomal dominant.
What is huntington’s diseases?
Neurodegenerative genetic disorder.
When does Huntington’s disease typically become noticeable?
- Mid-adult life (age 35-44).
- Usually fatal after 20 years.
7 symptoms/ presentations of Huntington’s disease?
- Earliest symptoms: mood or cognition problems.
- General lack of coordination/ unsteady gait.
- Movement become worse.
- Chorea-writhing movements.
- Decline in mental abilities.
- Behavioral and psychiatric problems.
- Problems swallowing, speaking and breathing.
Name 2 conditions present at birth that cause physical disability?
- Spina bifida.
- Cerebral palsy.
What is spina bifida? What causes it?
- Neural tube defect - tube does not close after 28 days.
- Exact cause unknown, but LACK OF FOLIC ACID before and in early pregnancy increases the risk.
When does the neural tube grow and what does it form?
- 1st month of life embryo grows neural tube.
- Forms SPINE and NERVOUS SYSTEM.
9 clinical presentations of a patient with spina bifida?
- Weakness or total paralysis of the legs.
- Bowel and urinary incontinence.
- Loss of skin sensation.
- Hydrocephalus.
- Usually normal intelligence.
- Repeated fits or seizures.
- Drooling problems and dysphagia.
- Communication and learning difficulties.
- Not progressive, life expectancy not affected.
What is cerebral palsy?
General term for a number of neurological conditions that affect movement and co ordination.
What causes cerebral palsy (2)?
Can occur if:
- Brain develops abnormally.
- Brain is damaged before, during or shortly after birth.
How common is cerebral palsy in the UK?
1/400 babies born in UK.
5 clinical presentations of a patient with cerebral palsy?
- Symptoms obvious WITHIN FIRST 3 YEARS.
- Muscle stiffness or floppiness.
- Muscle weakness.
- Random and uncontrolled body movements.
- Balance and co-ordination problems.
Name 3 serious illnesses affecting the brain, nerves or muscles that can cause physical disability?
- Motor neurone disease.
- Parkinson’s disease.
- Multiple sclerosis.
What is motor neurone disease? What causes it?
- Uncommon lethal degenerative disease affecting neurones.
- Aetiology unknown.
6 clinical presentations of a patient with motor neurone disease?
- Muscular atrophy, weakness and spasticity.
- No sensory loss.
- Dysphagia
- Drooling
- Speech difficulties
- Death within 5 years due to respiratory paralysis.
Life expectancy of someone with motor neurone disease?
Death within 5 years of diagnosis due to respiratory paralysis.
What is parkinson’s disease? What causes it (2)?
- Progressive neurological disease.
Causes: - Degeneration of the **pigmented cells* of the substantia nigra leading to dopamine deficiency.
- Previous head injury or cerebrovascular disease.
6 clinical presentations of a patient with parkinson’s disease?
- Tremor in arms and hands (pill rolling).
- Rigidity on movement.
- Slow movements and restlessness.
- Expressionless face.
- Stooped posture.
- Hypersalivation resulting in drooling saliva.
What is parkinson’s associated with?
Lewy body dementia
What have studies on professional footballers and rugby players shown?
- 3 times higher incidence of Parkinson’s.
- 15 times higher incidence of motor neurone disease.
What is multiple sclerosis/ what does it affect?
- Chronic, RELAPSING CNS disease affecting the cortico-spinal tract.
- Affects the myelin sheaths.
What is the mean age of onset of multiple sclerosis? Who does it affect mainly?
- Mean age of onset is 30 years.
- Females.
7 potential clinical presentations of a patient with multiple sclerosis?
- Optic neuritis can lead to blindness or visual disturbance.
- Nystagmus (jerky, oscillating movement of the eyes)
- Weakness or paralysis of limbs.
- Ataxia
- Dysphagia
- Loss of sphincter control leading to urinary incontinence.
- May present as V neuralgia or facial palsy
3 causes of spinal cord injuries?
- Trauma.
- Infection.
- Diseases.
Tetraplegic?
- Damage to spinal cord in the NECK. Affects ALL 4 LIMBS + TORSO. (ex. C4, C6 injury).
Paraplegic?
- Damage to MID/LOWER part of BACKS. Affects LEGS and LOWER BODY (ex. T6, L1, S1 injury).
5 causes of spinal injury?
- Falls- 41%
- RTAs- 36.8%
- Sports injuries
- Trauma
- Work related accidents
When are males and females more prone to spinal injury?
- Males: young adulthood 20-29) and elderly (>70).
- Females: 15-19 and 60+.
- M:F is 2:1.
2 types of trauma that can cause brain injury?
- External events: closed head trauma, missile penetrating the brain.
- Internal events: stroke, haemorrhage, tumor.
Another term for stroke?
Cerebrovascular accident.
8 clinical features of cerebrovascular accident?
- Face drooped on one side.
- Weakness/ numbness in one arm.
- Dysphagia.
- Aphasia
- Slurred speech (dysarthia).
- Sudden loss or blurring of vision.
- Confusion.
- Sudden and severe headache.
FAST.
4 considerations of stroke and dental health.
- Difficulty wearing dentures.
- Difficulty brushing teeth.
- Accessing the surgery, wheelchair transfer.
- Consent issues.
5 examples of physical disability.
- Missing limbs.
- Prosthetic limbs.
- Reduced manual dexterity.
- Stick/zimmer.
- Wheelchair.
6 potential difficulties with dental treatment for physically disabled.
- Attendance.
- Getting into dental chair.
- Positioning.
- Length of appointments.
- Compliance.
- Oral hygiene.
What is domiciliary care?
Providing dental treatment out with dental clinics for patients whose personal circumstances make it unfeasible to attend a dental clinic.
The equality acts 2010 states reasonable adjustments should be made so people with disabilities receive the same services, as far as possible, as someone not disabled. List 7 reasonable adjustments?
- Designated parking spaces.
- Ramps and lifts.
- Making doorways wider.
- Automatic doors.
- Hand rails.
- Lower reception desks.
- More lighting and clearer signs.
How does the UK department of health define disability (3)?
- Significant reduced ability to understand new or complex information.
- To learn new skills.
- Reduced ability to cope independently.
What IQ is considered learning disability?
IQ less than 70.
How many people in UK have learning disability? Severe?
- Approx 1.5M have LD.
- 350,000 have severe LD.
How is severity of learning disability categorized?
- Mild (can talk and look after themselves).
- Moderate.
- Severe
6 potentially associated clinical features of learning disability?
- Epilepsy.
- Visual defects.
- Hearing and speech difficulties.
- Facial deformities.
- Body-rocking and self-mutilation.
- Feeding difficulties.
4 causes of learning disability?
- Genetic.
- Problems during pregnancy.
- Problems during birth.
- Post-natal problems (early childhood illnesses, accidents, seizures).
3 postnatal problems that can result in learning disability?
- Early childhood illnesses.
- Accidents.
- Seizures.
What is the most common GENETIC cause of learning impairement?
Down syndrome.
How common is DS?
- 1 in 800 live births.
- Likelihood increases with mother’s age.
6 physical features of down syndrome?
- Atlanto-axial joint instability.
- Short stature.
- Brachycephaly.
- Widely spaced, upward slanting eyes.
- Weight gain.
- Brushfield spots.
8 associated health conditions of down syndrome?
- Cardiac problems.
- Spinal problems.
- Malignant disease.
- Dementia.
- Immune disease.
- Hearing loss.
- Visual defects.
- Seizures.
10 oral features of Downs Syndrome?
- Large tongue.
- Thick, dry, fissured lips.
- Poor anterior oral seal.
- Tongue thrust.
- Malocclusion.
- Delayed tooth eruption.
- Missing teeth.
- Morphological abnormalities.
- Cleft lip and cleft palate.
- Early onset periodontal disease.
How is autism spectrum disorder defined by the national autistic society?
A lifelong, developmental disability that affects how a person communicated with and relates to other people, and how they experience the world around them.
When does autism spectrum disorder start? Who is most often affected?
- Begins in FIRST 30 MONTHS of life.
- 4 times more common in boys than girls
4 characteristics of autism spectrum disorder?
- Poor social skills.
- Lack of interpersonal relationships.
- Delayed speech and language.
- Ritualistic, compulsive behavior.
6 conditions that may be associated with autism?
- Can have average or above average intelligence.
- Learning disabilities.
- ADHD or dyslexia.
- Anxiety or depression.
- Epilepsy.
- Visual/ hearing impairement.
8 clinical presentations of autism?
- Lives in own world.
- Unaware of others.
- Avoid eye contact.
- Echolalia.
- Obsessional desire to follow routine.
- Practice repetitive actions.
- Self mutilation.
- Sensitivity to touch, smell and sound.
5 oral findings in autistic patients?
- Bruxism.
- Traumatic lesions.
- Poor OH.
- Poor attendance.
- Prefer sweet foods.
9 dental management of autistic patients?
- Oral hygiene education and support.
- Previous training at school or home with visual aids.
- Pre-visit pack and questionnaire.
- Social stories/ story books/ makaton cards.
- Do not keep patient waiting.
- Short, quiet visit with same staff.
- Avoid aspirator, high speed.
- Have parent or carer present.
- Pain and anxiety control.
4 autism resources
- Making dental practices more autism friendly, Malcolm Hamilton for
Network Autism. - Preparing for a visit to the dentist.
- British Society for Disability and Oral Health.
- Advice for parents of children with autism, British Society of
Paediatric Dentistry.
6 ways to aid communication with patient with learning disabilities?
- Minimize distractions.
- Short explanations.
- Simple language.
- Tell show do.
- Picture maps.
- Makaton.
What is sensory impairment?
When ONE OR MORE of a person’s senses (sight, smell, hearing, touch, taste) is on longer normal. Does NOT have to be FULL loss of sense.
5 symptoms of visual impairement?
- Reduction/ loss of vision.
- Blurring of vision.
- Eye pain.
- Burning sensation.
- Gritty feeling.
5 causes of visual impairment?
- Glaucoma.
- Cataract.
- Macular degeneration.
- Diabetic retinopathy.
- Trachoma.
What causes glaucoma?
Rise in intraocular pressure.
When is glaucoma noticed (2)?
- Often picked up at routine eye test.
- Symptoms not generally noticed until there is marked visual loss.
4 clinical symptoms of glaucoma?
- Affects PERIPHERAL VISION first.
- Generally BILATERAL condition, affects one eye before the other.
- Blurred vision.
- Rainbow coloured circles around bright lights
Treatment for glaucoma (3)?
- Eye drops.
- Surgery.
- Laser treatment.
What is cataract?
- Clouding of the lens in the eye.
3 clinical features of cataract?
- Reduction in vision.
- Difficulty with bright lights and seeing at night.
- More common with age.
Treatment for cataract?
Artificial lens
What are the two types of macular degeneration?
Wet and dry
What causes wet macular degeneration?
Growth of new vessels under the retina which BREAK and LEAK INTO THE MACULA.
2 Symptoms of wet macular degeneration?
- Causes severe sight loss in a matter of MONTHS.
- RAPID loss of CENTRAL VISION.
What causes dry macular degeneration (2)?
- Hereditary element.
- Myopia may predispose.
3 symptoms of dry macular degeneration?
- BILATERAL condition.
- GRADUAL loss of CENTRAL vision.
- Person becomes unable to recognize people as cannot see faces clearly.
Major difference between wet and dry macular degeneration?
- Wet: causes RAPID loss of central vision.
- Dry: causes GRADUAL loss of central vision.
7 treatments for dry macular degeneration?
- None.
- Visual aids.
- Healthy diet (leafy greens, orange and yellow peppers).
- Healthy weight.
- Exercise.
- Stop smoking.
- Regular eye tests.
2 treatments for wet macular degeneration?
- Eye injections: Anti-VEGF medicines, aflibercept every 1,2,3 months.
- Photodynamic therapy: light destroys the abnormal blood vessels.
What predisposes to retinopathies?
Diabetes
What is the result of retinopathies?
Retinal degeneration and inflammation.
What is hemianopia?
Blindness in one half of the visual field.
What is the most common cause of hemianopia?
Variety of medical conditions, STROKE is most common.
Treatment of hemianopia? (5)
- Treatment depends on the condition diagnosed.
- EARLY diagnosis may be crucial.
- Medical.
- Surgical.
- Non invasive.
5 ways to prevent hemianopia?
- Regular eye exams.
- Protect eyes from sun.
- Stop smoking.
- Know FH.
- Seek treatment QUICKLY.
5 ways to communicate with someone who is visually impaired?
- Speak to them
- Information in large print- arial font
- Braille
- Picture mats
- Audio formats
How many people in UK are affected by hearing loss? What age?
- About 11 million peple.
- About 75% are above 60 years.
7 causes of hearing impairment?
- Excessive noise.
- Age.
- Infection/trauma.
- Drugs.
- Foreign bodies.
- Inherited.
- Congenital.
6 signs/ symptoms of hearing loss?
- Difficulty hearing people/ on the phone.
- Misunderstanding.
- Asking to repeat.
- Hard to keep up with convos.
- Feeling tired/stressed.
- Listening to music/ TV loud.
6 treatment and prevention strategies for hearing loss?
- Early detection.
- Early management – surgical or medical.
- Rehabilitation.
- Immunisation.
- Avoidance of some drugs.
- Reducing occupational exposure.
- Hearing aids.
3 types of hearing aids?
- Behind the ear.
- In the ear.
- In the canal.
4 types of hearing implant?
- Bone anchored hearing aids.
- Cochlear implant.
- Middle ear implant.
- Auditory brainstem implants.
9 ways of communication with a patient with hearing impairement?
- Printed information
- BSL interpreter
- Induction loop
- Infrared systems
- Bluetooth systems
- Text messaging
- Facial expressions and gestures.
- Do not turn face away.
Define dementia?
- Loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.
- NOT a natural part of aging
Incidence of dementia in the UK (3)?
- 2024 - 1 million people (expected to increase).
- 1 in 3 people > 65 will develop dementia.
- 1 in 6 people > 80 have dementia.
What is the biggest risk factor for dementia?
Age
8 risk factors for dementia?
- Age.
- Gender (F).
- Ethnicity.
- Genetics.
- Down syndrome.
- Medical factors (type II diabetes, high cholesterol, hypertension, obesity, depression).
- Lifestyle factors (lack of exercise, unhealthy diet, smoking, excessive alcohol).
- Head injuries.
5 medical factors that increase risk of dementia?
- Type II diabetes.
- Hypertension.
- High cholesterol.
- Obesity.
- Depression.
4 lifestyle factors that can increase the risk of dementia?
- Physical inactivity.
- Unhealthy diet.
- Smoking.
- Excessive alcohol.
How big of an effect do risk factors have on dementia?
- 14 health issues which if reduced/ eliminated could prevent NEARLY HALF OF DEMENTIA WORLDWIDE.
- 45% of our risk can be changed.
What is the dementia caused by head injuries in sports called?
CHRONIC TRAUMATIC ENCEPHALOPATHY.
The link between football and dementia (UoG study) (2)? What intervention came out of it?
- 3.5x more likely to suffer dementia.
- 5x more times likely to die from Parkinson’s disease.
- Children under 12 banned from heading footballs in training.
7 ways to reduce dementia risk factors?
- Be physically active.
- Stop smoking.
- Eat healthily.
- Healthy weight.
- Reduce alcohol consumption.
- Keep mentally active.
- Be social.
5 types of dementia?
- Alzheimer’s disease.
- Vascular.
- Mixed.
- Lewy-body.
- Fronto-temporal.
What is the most common form of dementia?
- Alzheimer’s Disease.
- Accounts for 62% of dementia.
4 clinical symptoms/ presentation of Alzheimer’s disease?
- Short-term memory loss.
- Word finding difficulties.
- Progressively more confusion.
- May experience MOOD SWINGS, FRUSTRATION, BECOME MORE WITHDRAWN.
4 changes to the brain in alzheimer’s disease?
- Amyloid plaques.
- Tangles in tau proteins.
- Loss of connections between neurons.
- Decrease in acetylcholine.
3 infections that can increase the risk of alzheimer’s disease?
- Oral herpes.
- Pneumonia.
- Spirochete bacteria.
Link between periodontal disease and Alzheimer’s (2)?
- Gingivitis is more common among patient with Alzheimer’s.
- Porphyromonas gingivalis - proteins produced by p.gingivalis are present in higher concentrations in brain.
What periodontal pathogen may be associated with Alzheimers disease?
Porphyromonas gingivalis
What is the second most common type of dementia?
- Vascular dementia.
- 17% of cases.
What causes vascular dementia (2)?
- Caused by reduced blood flow to the brain.
- Often diagnosed after a stroke or series of TIAs.
Clinical presentation of vascular dementia (2)?
- Step wise deterioration.
- Linked to cerebrovascular changes in the brain.
What is the third most common type of dementia?
- Mixed dementia.
- 10% of cases.
What is mixed dementia?
A combination of Alzheimer’s disease and vascular dementia.
Difference between progression of alzheimer’s and vascular dementia?
- Alzheimers: PROGRESSIVE.
- Vascular dementia: STEP-WISE.
What is the 4th most common type of dementia?
- Lewy body dementia.
- 4% of cases.
What are lewy bodies?
Small deposits of protein in nerve cells.
7 clinical presentations of lewy body dementia?
- Problems with thinking, movement, behavior and mood.
- Unpredictable changes in attention and alertness.
- Visual hallucinations.
- Disturbed sleep.
What disease is lewy-body dementia associated with?
Parkinson’s disease.
When does fronto temporal dementia occur (2)?
- Generally affects people slightly younger.
- Symptoms present in 6th decade.
5 clinical presentation of fronto-temporal dementia?
- Personality change.
- Challenging behavior (ex. disinhibition).
- Short temperedness/ agression.
- Mood swings.
- Sexually inappropriate behavior.
5 steps/ ways of diagnosing dementia?
- Attend GP.
- Personal and medical history.
- Physical exam and other investigations (bloods, urine, ECG).
- Review medication that can adversely affect cognitive functioning.
- Check mental abilities.
What questionnaire can be used to help diagnose dementia?
Mini mental state exam (MMSE).
6 things the mini mental state exam tests?
- Short and long term memory.
- Attention span.
- Concentration.
- Language and communication skills.
- Ability to plan.
- Ability to understand instructions.
5 tests to check for dementia?
- Mini mental state exam.
- Abbreviated Mental Test Score (AMTS)
- 6-Item Cognitive Impairment Test (6-CIT)
- General Practitioner Assessment of Cognitition (GPCOG)
- 7 minute screen.
Who can you refer to to confirm dementia diagnosis (3)?
- Specialist dementia diagnostic service, MEMORY CLINIC.
- Old age psychiatry.
- Geriatrician.
2 scans that may be taken to confirm dementia diagnosis?
- CT/MRI.
- Perfusion scan.
3 treatments for dementia?
- NO CURE.
- Talking therapies (counselling, CBT).
- Reducing cardiac risks may halt deterioration of vascular type dementias.
- NSAIDs may slow progression.
What is the drug treatment for alzheimers disease? (4)
- Donepezil - mild to moderate Alzheimer’s.
- Galantamine.
- Rivastigmine.
- Memantine (blocks the effects of glutamate, moderate to severe alzheimer’s).
- Only effective for ALZHEIMERS and PARKINSONS DEMENTIA.
What drug is effective for mild to moderate alzheimer’s?
Donepezil
What drug is appropriate for moderate to severe Alzheimer’s? How does it work?
- Memantine
- Blocks the effects of glutamate.
What are the new types of drugs that target alzheimers? How are they administered? How do they work? What is their effect?
- Immunotherapy drugs.
- IV infusions.
- Target amyloid.
- Slow progression of Alzheimer’s.
4 new drugs that help slow the progression of Alzheimer’s?
- Lecanemab.
- Remternetug.
- Donanemab.
- Miridesap.
What is the effect of Lecanemab (2)? How is it given?
- 1st drug to convincingly slow progression of early stage Alzheimer’s.
- Shown to slow cognitive decline by 1/4th over the course of 18 months.
- Given as IV infusions every 2 weeks.
- Not available on NHS.
3 stages of dementia?
- Early.
- Middle.
- Late.
7 clinical presentations of EALR DEMENTIA?
- Changes in ability and behavior may be MILD.
- Often misattributed to stress, bereavement or aging.
- Loss of short-term memory.
- Confusion, poor judgement, unwilling to make decisions.
- Anxiety, agitations.
- Inability to manage everyday tasks.
- Communication problems.
6 ways a dentist may notice early stages of dementia?
- Forgotten appointments.
- Forgotten conversations.
- Repetitions.
- Confusion in grasping new ideas.
- Difficulty making decisions.
- Deterioration in oral hygiene.
6 clinical presentations of middle stage dementia?
- More support in day to day life (reminders to eat, wash, dress, toilet).
- Increasingly forgetful and may fail to recognize people.
- Distress, aggression, anger, mood changes.
- Risk of wandering or getting lost.
- May behave inappropriately (ex. pajamas out).
- May experience hallucinations/ throw back memories.
3 ways the dental team may notice middle stage dementia?
- Patient may not recognize dental team.
- Repeats questions forgetting answer given.
- May appear confused and agitated.
4 things to consider regarding dental appointments for patients with middle stage dementia?
- Helpful to bring someone with them (ex. partner, carer).
- What time is best?
- Longer appointments.
- Assess capacity/ consent.
How to communicate with a patient who has middle stage dementia (5)?
- Simple, clear and slow
- Time
- Body language
- Repeat
- Inclusion in conversation
6 aspects to consider when treatment planning for someone with middle stage dementia?
- PREVENTION.
- Oral hygiene.
- Polypharmacy
- Simple treatment plans.
- Reliance on others.
- Consent.
How does dementia progressions affect co operation for treatment?
Co operation declines as dementia progresses.
4 things that may make GA more complex in dementia patients?
- Age.
- Frailty.
- Co morbidities.
- Dementia can worsen following GA.
7 clinical presentations of late stage dementia?
- Increasingly dependent on others for their care.
- Inability to recognise familiar objects, surroundings or people. May be some flashes of recognition.
- Increased physical frailty- eventually confined to wheelchair or bed.
- Difficulty eating and swallowing, weight loss, incontinence and gradual loss of speech.
Dental aspects of late dementia (7)?
- Difficult for patient to come to dental surgery.
- Difficulty eating and swallowing.
- Weight loss.
- Difficulty wearing dentures.
- Loss of speech and communication difficulties.
- Focus on making mouth comfortable AND that carers carry out regular OH.
8 ways to tell a patient with late stage dementia is experiencing dental pain?
- Refusal to eat (particularly cold or hard foods).
- Pulling at face or mouth.
- Leaving previously worn dentures out.
- Increased restlessness, moaning, shouting.
- Disturbed sleep.
- Refusal to take part in daily activities.
- Agression.
- Swelling.
What does playlist for life do (3)?
- Response to music is the last sense to go at the end of life.
- Music alleviates dementia symptoms such as anxiety & agitation, reducing need for meds.
- Helps family members reconnect.
What are the 2 types of bleeding disorders?
- Platelet disorders.
- Clotting disorders.
4 stages of normal hemostasis?
- Blood vessel constriction.
- Platelet plug.
- Activation of coagulation - stable fibrin plug.
- Activation of fibrinolysis - clot dissolution.
3 types of platelet disorders?
- Failed platelet production.
- Excessive platelet destruction.
- Abnormal platelet function.
Define thrombocytopenia?
Too little platelets.
What is normal platelet level?
150-300 x 10^9/L
8 causes of thrombocytopenia?
- Autoimmune.
- Alcoholism.
- Liver problems - cirrhosis and hepatitis.
- Infections (HIV, EBV).
- Bone marrow diseases.
- Cancer.
- Cancer treatments.
- Glanzmanns disease.
2 infections that can cause thrombocytopenia?
HIV, EBV
How is glanzmanns disease inherited? What does it affect? What does it cause (3)?
- Autosomal recessive.
- Affects platelet aggregation.
- Epistasis, menorrhagia, gingival hemorrhage.
2 things you must do prior to treating a patient with a platelet disorder?
- Liaise with Hematology/ Oncology.
- FBC prior to procedure.
Required platelet levels for extraction?
Platelet levels above 50 x 10^9/L
Required platelet levels for major surgery?
Platelet levels above 70 x 10^9/L
4 ways platelet disorders can be treated?
- Steroids: immunosupression, reduce destruction of platelets.
- Eltrombopag: stimulates platelet production in bone marrow.
- Tranexamic acid: Antifibrinolytic action.
- Platelet transfusion
What is tranexamic acid used for? How does it work? 2 ways fo administration?
- To treat or prevent excessive blood loss.
- Antifibrinolytic action.
- Mouthwash, tablets.
How many clotting factors do we have?
12
Name 3 clotting disorders
- Von Willebrand’s disease.
- Haemophilia A (factor 8).
- Haemophilia B (factor IX).
What is the most common bleeding disorder?
Von Willebrand’s disease - 1% of population.
How is vWD inherited?
Autosomal dominant.
What are the 3 types of vWD?
- Mild (70% of cases)
- Moderate
- Severe (rare - total absence of vWF)
2 function of Von Willebrand factor?
- Essential co-factor for normal platelet adhesion.
- Carrier for Factor VIII.
6 symptoms of vWD?
- Excessive bleeding from injury, surgery, dental extraction.
- Frequent nosebleeds.
- Heavy periods.
- Blood in urine or stool.
- heavy bleeding during labour and delivery.
- Easy bruising of lumpy bruises.
3 treatments for vWD?
- Tranexamic acid.
- Desmopressin.
- Factor VIII (severe).
What is desmopressin? What are its 2 functions? 4 ways it can be administered?
- Synthetic version of vasopressin.
- Stimulates the release of vWF and increase in factor VIII levels.
- IV, IM, SC, Intranasal.
How is haemophilia inherited (6)?
- 70% positive family history.
- 30% new mutation.
- X linked recessive.
- Males affected.
- All daughters carriers.
- Carries may have bleeding tendency.
How common is Haemophilia A?
- Factor VIII deficiency: 1/5000 live male births.
How common is Haemophilia B?
- Factor IX deficiency: 1/20000 live male births.
What does the severity of hemophilia depend on? Clotting factor levels at 3 severities?
- Depends on level of clotting factor
- Mild- 5-50%
- Moderate- 1-5%
- Severe- less than 1%
6 symptoms of haemophilia?
- Nosebleeds
- Prolonged bleeding from wounds.
- Bleeding gums
- Skin that bruises easily
- Pain and stiffness around joints
- Internal bleeding
What is one of the most common causes of life threatening bleeds in severe hemophelia patients?
Bleeding after dental extractions.
What is the effect of prophylaxis on severe hemophelia?
Maintains factor VIII levels at moderate levels.
What does the world federation of hemophilia say about the treatment of hemophilia patients in dental practice?
- Majority of patients can be safely treated in general practice for routine dentistry
- Only severe cases of haemophilia, those with inhibitors or rare bleeding disorders should be routinely referred to the Dental Hospital for routine dentistry.
According to WFH guidelines, 6 things that REQUIRE hemostatic cover?
- Extractions.
- Oral surgery.
- Implant surgery.
- Periodontal surgery.
- IDBs, lingual infiltrations.
According to WFH guidelines, 4 things that DO NOT REQUIRE hemostatic cover?
- Buccal infiltration.
- Palatal infiltration.
- Intraligamental injection.
- Intrapapillary injection.
4 steps to undertake when planning an extraction in a hemophilia patient?
- Liase with Haemophilia centre to organise factor replacement therapy
- Use of buccal articaine
- Tranexamic acid mouthwash and/or tablets
- Topical haemostatic agents- pressure packs, sutures, oxidized cellulose (Surgicel), Fibrin glue
4 types of topical hemostatic measures?
- Pressure packs
- Sutures
- Oxidized cellulose (Surgicel)
- Fibrin glue
3 things regarding providing periodontal treatment for GINGIVITIS patients with hemophilia?
- No factor replacement required.
- tranexamic acid mouthwash to manage post-op bleeding.
- Disclosing agents to demonstrate plaque.
4 things regarding providing periodontal treatment for PERIODONTITIS patients with hemophilia?
- Prolonged bleeding can be encountered.
- No factor replacement required.
- Pre and post op tranexamic acid advised.
- Severe cases may require factor replacement.
3 BEHAVIORAL challenges of patients with bleeding disorders? Effect?
- Reluctance to brush teeth due to fear of bleeding
- Reluctance to access regular dental care due to fear of haemorrhage
- Poorer attendance
- Increased rate of extractions
3 challenges with hematological cover?
- Patients develop inhibitors to replacement clotting factor
- Require more expensive drugs
- More severe bleeding
2 types of drugs that affect bleeding?
- Anti-platelet (aspirin, clopidogrel).
- Anticoagulant (warfarin, heparin, dabigatran, apixaban, rivaroxaban, edoxaban).
2 antiplatelet medications
- Aspirin.
- Clopidogrel.
4 types of blood cancer?
- Myeloma.
- Lymphoma.
- Leukemia.
- Myelodysplasia.
What is multiple myeloma? What does it result in?
- Plasma cell neoplasm.
- Production of abnormal serum immunoglobulins (antibodies).
Who does multiple myeloma usually affect? When do symptoms appear? What may it be related with (2)?
- Mainly people over age 60.
- Many years before symptoms appear.
- Sometimes related to radiotherapy or petroleum products.
3 ways to diagnose multiple myeloma?
- Blood tests.
- CT/MRI scan.
- Bone marrow biopsy.
7 symptoms of multiple myeloma?
- Bone infiltration and destruction
- Bone pain
- Pathological #
- Hyperviscosity syndrome
- Renal failure
- Anaemia
- Neurological lesions
Dental effects of multiple myeloma (7)?
- 70% of cases skull is affected.
- Pathological #
- Mental anesthesia.
- Root resorption.
- Loose teeth.
- Bisphosphonates.
- Rare cause of mandibular radiolucencies.
8 systemic manifestations of multiple myeloma that may affect dental treatment?
- Anemia.
- Renal failure.
- Hemorrhagic tendencies.
- Infection.
- Chemotherapy.
- Steroids.
- Bisphosphonates.
- Biological therapies.
- Liase with hematology.
What are the 4 different types of leukaemia?
- Acute: Acute lymphoblastic leukaemia OR acute myeloid leukaemia.
- Chronic: Chronic lymphocytic leukaemia, chronic myeloid leukaemia.
Who is acute lymphoblastic leukiamia more commonly seen in?
commonest in CHILDREN.
Who is acute myeloid leukaemia most often seen in? Prognosis?
More common IN ADULTS. POOR prognosis.
What caues chronic leukaemia (1)? Who is it most often seen in? Prognosis?
- Proliferation of more mature cells.
- More common in ADULTS.
- Prognosis BETTER.
Which type of leukaemia is more common in children?
Acute lymphoblastic leukaemia.
Clinical presentation of chronic leukaemia (3)?
- Some patients ASYMPTOMATIC.
- May present with: splenomegaly, lymph node enlargement.
5 treatment options for leukaemia?
- Chemotherapy.
- Radiotherapy.
- Immunotherapy.
- STEM cell transplant.
- Tyrosine kinase inhibitors.
5 systemic manifestations of leukamia that can affect dental treatment/ can have dental effects?
- Crowding out of normal blood cells by the leukaemic cells.
- Anemia.
- Bleeding tendencies.
- Susceptibility to infections.
- Septicaemia from oral infections.
Dental manifestations of leukaemia? (4)
- Mucosal pallor.
- Ulceration.
- Gingival swelling.
- Spontaneous bleeding.
What is lymphoma?
Cancer of lymph glands or other organs of the lymphatic system.
What are the two types of lymphoma?
Hodgkin’s and Non Hodgkin’s lymphoma.
4 symptoms of lymphoma?
- Non tender swollen lymph nodes.
- Fever.
- Night sweats.
- Unexplained weight loss.
How does hodgkin’s lymphoma develop? What is it characterized by? Who is it most often seen in?
- Develops from B lymphocytes.
- Characterized by Reed-Sternberg cells.
- Young adults and people >75.
How is hodgkins lymphoma treated?
Aggressive - Chemotherapy, radiotherapy.
How does non hodgkin’s lymphoma develop? How many types? Who is it most often seen in?
- Affects either B or T lymphocytes.
- More than 30 different types.
- Any ages but risk INCREASES WITH AGE > 1/3 over 75.
What does treatment of lymphoma depend on (4)? Treatment for low grade? High grade (3)?
- Depends on type, grade and extent of lymphoma, age.
- Low grade: watch and wait.
- High grade: chemotherapy, radiotherapy, monoclonal antibodies: rituximab.
What is myelodysplasia (3)?
- Rare type of blood cancer.
- Don’t have enough healthy blood cells –> Bone marrow makes abnormal cells instead of healthy blood cells (RBC, WBC, platelets).
- Immature blood cells squeeze out the healthy ones.
Who is myelodysplasia most often seen in? How fast does it develop? What can it develop into?
- Most common in adult over the age of 70.
- Can develop slowly or quickly.
- Can develop into AML.
5 systemic symptoms of myelodisplasia?
- Weakness
- Tiredness.
- Breathlessness.
- Frequent infections.
- Bruising and easy bleeding, ex. nose bleeds.
7 treatments of myelodysplasia?
- Injections of growth factor medicines to increase number of blood cells, ex. erythropoeitin.
- Antibiotics.
- Biological therapies, ex. Lenalidomide.
- Chemotherapy.
- Immunosuppressants.
- Blood transfusion.
- Stem cell (bone marrow) transplant.
Dental aspects of myelodysplasia (8)?
- Risk of bleeding - platelets, clotting.
- Timing of extractions.
- Platelet transfusion.
- Infection - antibiotics?
- Steroids.
- Chemotherapy.
- MRONJ.
- Sepsis.
3 overall themes to follow for dental treatment on patients with blood cancers?
- Dental screening prior to treatment.
- Make patient dentally fit.
- Liaise with Hematology consultant.
Define MRONJ
Exposed bone in the maxilla or mandible that has persisted for more than 8 weeks in patients taking anti-resorptive or Antiangiogenic drugs and where there is no history of radiation or no obvious metastatic disease to the jaws.
MRONJ symptoms (6)?
- Delayed healing after extraction or other trauma.
- Sometimes spontaneous without an obvious trauma.
- Pain.
- Soft tissue infection and swelling.
- Numbness.
- Exposed bone - sometimes absent.
What is the incidence of MRONJ (2)?
- Cancer patients treated with anti-resorptive or anti-angiogenic drugs 1% (1 case per 100).
- Osteoporosis patients treated with anti-resorptive drugs 0.01-0.1% (1-10 cases per 10,000).
4 risk factors to MRONJ?
- Underlying medical condition.
- Concurrent treatment with steroids.
- Cumulative drug dose.
- Surgery/trauma.
3 medications that increase MRONJ risk?
- Bisphosphonates.
- RANKL inhibitors.
- Anti angiogenic drugs.
What do bisphosphonates do? What are they used for?
- Reduce bone resorption by hindering the formation, recruitment and function of osteoclasts.
- Most commonly used for osteoporosis.
- Also used in management of other malignant and non-malignant conditions.
What is a benefit of bispshosphonates for patients?
Reduce or delay the onset of disease or treatment complications, ex. bone fractures, pain.
How long do bisphosphonates last in the body? Why?
- Have a high affinity for hydroxyapatite and persist in the skeletal system for years.
- Half life of alendronate is around 10 years.
Where do bisphosphonates accumulate? Why is this bad?
- Accumulate at sites of high bone turnover (ex. jaw).
- May reduce bone turnover, bone blood supply and lead to death of bone –> OSTEONECROSIS.
Name 2 oral and 2 IV bisphosphonates?
- Oral: alendronic acid, risedronate sodium.
- IV: pamidronate, zolendronic acid.
What are RANKL inhibitors? How do they function?
- Anti-resorptive drugs.
- Inhibit osteoclast function and bone resorption.
What are RANKL inhibitors used for? (2)?
- Reduce risk of fracture and chronic pain in osteoporosis.
- Also used in cancer.
Name a RANKL inhibitor
denosumab
How often are RANKL inhibitors given for osteoporosis? for cancer?
- 6 monthly for osteoporosis.
- Every month for cancer.
How long do RANKL inhibitors last?
Effects diminish within 9 months of treatment completion
What are anti-angiogenic drugs used for? 3 named examples?
- Treatment of cancer.
- Restrict the growth of tumor blood vessels.
- lenalidomide, aflibercept, Sunitinib.
Drug holidays for bisphosphonates and RANKL inhibitors?
- Bisphosphonates: no evidence to support drug holidays. Drug remains embedded in bone with a half life that can be several decades.
- RANKL inhibitors: Denosumab guidance states a 9 month stop prior to XLA, weak evidence and 9 month gap in tx not always practical.
use of antibiotics for MRONJ (2)?
- Insufficient evidence to support prophylactic use of antibiotics to reduce risk of MRONJ following XLA.
- Only consider when clear evidence of infection and that patient will benefit from them.
What GDC standard is concerned with valid consent? List 3 of its sub-standards.
- GDC standard 3.
- 3.1 You must obtain valid consent before starting treatment, explaining all relevant options and possible costs.
- 3.1.4 You must check and document that patients have understood the information you have given.
- 3.2 You must make sure that patients (or their representatives) understand the decisions they are being asked to make.
3 aspects of valid consent?
- Informed.
- Given freely.
- Capable patient.
What does incapacity mean (5)?
AMCUR.
Incapable of:
- ACTING.
- MAKING a decision; or.
- COMMUNICATING a decision; or
- UNDERSTANDING a decision; or
- RETAINING memory of the decision
In relation to any particular matter due to mental disorder or an inability to communicate.
What is important about capacity?
ACTION/ DECISION SPECIFIC - must check person’s capacity relative to the issue.
3 ways to check the patient has understood and has capacity to consent?
- Open questions.
- Chunk and check.
- Teach back.
When does the Adults with Incapacity Act 2000 apply?
When a person lacks capacity to consent to dental treatment.
What does the adults with incapacity act 2000 do? 2 other facts.
- Safeguards the WELFARE and manages the FINANCES of people aged 16 years and over who LACK CAPACITY.
- In Scotland, there is a presumption “in favor” of capacity.
- Capacity is NOT “all or nothing”. It is action or decision specific.
If a person lacks capacity to consent to dental treatment, what should be done?
A Section 47 certificate should be issued.
What are the 5 key principles of a section 47 certificate?
- BENEFIT.
- LEAST restrictive of freedom.
- The person’s past and present WISHES should be taken into account.
- CONSULT relevant others.
- Encourage RESIDUAL capacity.
What is a proxy (4)?
Someone who has been authorized to act on behalf of an adult with incapacity.
- Substitute decision maker, legally recognized, different types to be aware of.
What is a power of attornery?
Granted by the adult whilst they have capacity to choose who they wish to act on their behalf should the need arise.
3 types of power of attorney?
- Welfare.
- Continuing (money, property, business).
- Joint/ combined.
4 facts about the power odf attorney?
- Must be in WRITING.
- Must be registered with OFFICE of THE PUBLIC GUARDIAN (OPG).
- Powers are DORMANT until needed.
- DO NOT have an expiry date.
Why are there different types of power of attorney?
Up to the individual which powers they wish to grant.
How must the PoA document be provided (3)?
- Ask to see ORIGINAL or LAWYER ENDORSED copy.
- Electronic versions DO NOT have embossed seal.
What must you check in the PoA document (3)?
- Must check what powers have been granted.
- Need to read the BODY of the document.
- Not all WPoA have the right to consent.
How can you check what powers a PoA has been granted?
- Check the PoA documents.
- Check with the OPG.
What sentence should be seen in the WPoA document that shows the WPoA can consent to tx?
The power to consent or withhold consent to medical and dental treatment.
When does a PoA gain power?
The powers are DORMANT until it is demonstrated that the patient DOES NOT HAVE CAPACITY to make the necessary decision.
3 other useful information about WPoA?
- A person can grant power to more than one attorney.
- A person can also specify a substitute attorney.
- Substitutes may be needed if the attorney becomes incapable, resigns or dies.
3 things a WPoA CANNOT do?
- Cannot have more power than a capable patient.
- Cannot authorize use of force.
- Exclusion to certain treatments (not relevant to dentistry).
5 key points about WPoA?
- Granted when a person is capable.
- They can choose whomever they wish.
- Must be in WRITING and registered with OPG.
- PoA DONT have an EXPIRY DATE.
- Must check what powers have been granted.
When is a guardian granted (2)?
When an adult either:
- No longer has capacity to choose who they wish to make decisions for them.
- The adult has never been able to make their own decisions.
How does a person get a guardian (4)?
- Court process.
- Awarded by SHERIFF.
- Requires medical and social work reports.
Requirements for a Guardian (3)?
- Must be registered with the OPG.
- Continuous powers.
- Has an EXPIRY DATE.
3 types of guardianship powers?
- Welfare.
- Financial/ property.
- Both.
What is the process of checking the documents of a Guardian (6)?
Same as for PoA.
- Original or lawyer endorsed copy.
- Digital lacks embossed stamp.
- Need to read body of document: power to consent or withhold consent to medical and dental treatment.
- Must check what powers have been granted.
- Can check with OPG.
3 key differences between WGuardian and WPoA?
- Different process to get one (court, granted by sheriff).
- WGuardian has expiry date (usually appointed for 3 years).
- Can authorize use of force.
9 key points about WG?
- Granted by a SHERIFF, NOT the individual.
- Court process.
- Registered with OPG.
- Used when capacity already lost or patient never able to make own decisions.
- Has an expiry date.
- Not all the same.
- Must check what powers have been granted.
- Sheriff can appoint more than one.
- Sheriff can appoint a substitute.
What is the expiry date of WG?
Usually appointed for 3 years.
What is an intervener?
Appointed for a one-off event.
When checking proxy status with the OPG, what can they (2) and cant they (2) confirm?
Can confirm:
- Proxy in place.
- If welfare powers exist.
Cant confirm:
- What they are.
- Cant give contact details.
Who can consent to dental treatment (4)?
- Patients with capacity.
- WPoA and WG who HAVE POWER TO CONSENT.
- Medical and Dental practitioners (with additional training) can AUTHORIZE treatment under section 47 of AWI act.
Can a dentist authorize treatment under section 47 (2)?
- Yes but with ADDITIONAL TRAINING.
- Can only authorize DENTAL TREATMENT.
How to consent a patient for treatment when there IS a proxy (3)?
If the patient is deemed to NOT HAVE CAPACITY for the particular decision and there IS A PROXY with the relevant welfare powers:
1. Follow the 5 Key Principles of AWI.
2. Get CONSENT from the proxy.
3. Have an AWI (S47) certificate issued.
How to consent a patient for treatment when there IS NOT a proxy (3)?
If the patient is deemed to NOT HAVE CAPACITY for the particular decision and there IS NOT A PROXY with the relevant welfare powers:
1. Follow the 5 Key Principles of AWI.
2. Have an AWI (S47) certificate issued.
3. The S47 certificate authorizes the treatment to go ahead.
Who is able to complete an AWI certificate (2)?
- Doctors.
- Health professionals who have successfully completed relevant training in the assessment of capacity, including dental practitioners, ophthalmic opticians and registered nurses.
When is an adults with incapacity certificate (S47) required?
S47 is ALWAYS required to allow (non-emergency) treatment to be given if a patient is incapable, EVEN WHEN THEY HAVE A PROXY.
Can a relative who is not a proxy give consent?
NO.
5 renal functions?
- Excretion of waste products
- Maintaining fluid and electrolyte balance
- Acid-base balance
- Secretion of hormones- renin, erythropoietin, activate
vitamin D - Excretion of drugs
3 causes of acute renal failure?
- After surgery
- After severe injury
- Renal vessels become obstructed
How is chronic kidney disease defined?
- Kidney damage
- Reduction in glomerular filtration rate for 3 or more months
Who is more at risk of chronic kidney disease? (3)
- W>M.
- South asian or african heritage
3 most common causes of chronic kidney disease?
- hypertension
- glomerulonephritis
- diabetes
2 tests to check for chronic kidney disease?
- Blood test to check kidney function.
- Urine test to assess kidney damage
When does chronic kidney disease present with symptoms?
When kidney function is less than 25% of normal
5 stages of chronic kidney disease?
- Early (no symptoms).
- Mild
- Moderate
- Severe
- End stage renal failure
11 clinical features of chronic kidney disease?
- Depression, lethargy
- Weakness, fatigue
- Nausea, vomiting, anorexia.
- Peptic ulceration
- Bruising
- Diarrhea
- Bone pain
10 oral findings of chronic kidney disease?
- Reduced salivary flow rate.
- Dry mouth
- Halitosis
- Metallic taste
- Accelerated calculus production
- Oral ulceration
- Edema
- Paraesthesia
- Pale oral mucosa
- Protein and electrolyte changes.
3 important points regarding the dental management of patients with chronic kidney disease?
- Increased bleeding risk.
- Increased risk of infections.
- Poorly controlled infections may spread and cause SEPTICAEMIA.
5 dietary guidelines for patients with chronic kidney disease?
- Limit salt and sodium to CONTROL BLOOD PRESSURE.
- Limit PHOSPHOROUS as it pulls CALCIUM from bones.
- Limit POTASSIUM as it can cause HEART PROBLEMS.
- Eat the right proteins in the right amounts.
- FLUID RESTRICTION (stages 4 and 5 - depends on kidney function, type of dialysis and diuretic therapy).
2 types of renal dialysis?
- Hemodialysis.
- Peritoneal dialysis
Where is haemodialysis perfomed? How? What does it do?
- Performed in health centres or hospitals.
- Requires ARTERIO-VENOUS ACCESS.
- Patient is HEPARINISED.
- Removes excess fluid and uraemic solutes
How often is hemodialysis performed? For how long?
3 times a week for 4 hours
Where is peritoneal dialysis performed? How? When?
- Performed at home by patient or carer.
- CATHETER is placed in the PERITONEAL CAVITY.
- Dialysis fluid is exchanged at regular intervals.
5 considerations for dental treatment in patients undergoing renal dialysis?
- Bleeding
- Infection
- Drug interaction (avoid aspirin, NSAIDs).
- Toxicity and dosage
- Consult renal physician
- Best time for treatment is day after hemodialysis
- Avoid aspirin and NSAIDs.
- Lower doses of drugs.
- Safest treatment is LA.
- Extractions - FBC & coagulation screen
when is the best time for dental treatment in a patient undergoing renal dialysis?
Day after haemodialysis
What must be done for extractions in patients undergoing renal dialysis?
- Full blood count
- Coagulation screen.
7 dental goals to be completed before a patient receives a kidney transplant?
- Full dental assessment.
- Cons
- Scaling
- Prevention
- Extract poor prognosis teeth
- Eradicate sources of potential infection.
- OVERALL MAKE PATIENT DENTALLY FIT.
The risk of what tumor increases when a patient receives a renal transplant?
KAPOSIS SARCOMA (oral tumor)
5 effects of a renal transplant?
- Lifelong immunosuppression (cyclosporin, tacrolimus)
- Gingival hyperplasia.
- Increased risk of oral tumors (kaposis sarcoma).
- Candidiasis.
- Herpes Simplex
6 considerations regarding dental treatment post transplant
- CONSULT WITH RENAL PHYSICIAN.
- Early post-operative months BACTERIAL SEPSIS is a common complication.
- Delayed wound healing.
- Infection risk.
- Defer elective dental care for 6 months.
- Antibiotic cover within first 6 months.
2 aims of the dental team when providing pre-treatment of radiotherapy, chemotherapy?
- Remove potential sources of infection.
- Cancer treatment can proceed without delay.
How does radiotherapy work (5)?
- Uses IONIZING RADIATION.
- Radiation kills DNA OF CANCER CELLS.
- “Blunt tool” - DESTROYS HEALTHY CELLS TOO.
- SALIVARY GLANDS very sensitive.
3 types radiotherapy?
- Conventional
- Intensity modulated radiation therapy (IMRT).
- Rapid arc
4 general side effects of radiotherapy?
- Fatigue
- Nausea
- Pain
- Burns
7 oral side effects of radiotherapy?
- Mucositis
- Xerostomia
- Radiation caries
- Periodontal disease
- Dysgeusia/ ageusia
- Trismus
- Osteoradionecrosis
What is the scale for oral mucositis?
0-4
Grade 0 mucositis?
No mucositis
Grade 1 mucositis (4)?
- ERYTHEMA but NO ULCERATION.
- Feels like sunburn but in the mouth.
- ICE is useful.
- Patient can eat normally.
Grade 2 mucositis (4)?
- ULCERATION (with/without erythema).
- PAINFUL.
- Can swallow a solid diet.
- May require MORPHINE for the pain.
Grade 3 mucositis (4)?
- ALOT OF ULCERATION.
- VERY PAINFUL.
- ABLE TO SWALLOW LIQUIDS BUT NOT SOLID DIET.
- May have to be fed PARENTRALY.
Grade 4 mucositis?
- ULCERATION and/or NECROSIS
- EXTREMELY PAINFUL.
- ALIMENTATION NO LONGER POSSIBLE (NG TUBE).
3 adjunctive treatments to surgical excision of cancer?
- Chemotherapy.
- Radiotherapy.
- Chemoradiotherapy.
What do you advise the patient regarding dysgeusia/ ageusia induced by radiohterapy?
May recover after 9-18 months. May be PERMANENT.
What is essential in cancer patients about to undergo H and N radiotherapy?
PRE TREATMENT SCREENING ESSENTIAL. (prevention better than cure)
8 dental interventions we can do to make a patient dentally fit for radiotherapy?
- Extraction of hopeless teeth.
- Duraphat toothpaste and varnish.
- Fluoride trays.
- Hygiene phase therapy.
- Therabite.
- Pharmaceuticals (pentoxylline, vitamin E/tocopherol
- Hyperbaric oxygen.
- Low level laser therapy.
5 examples of “hopeless teeth”
- Gross caries.
- Mobility (grade 2+).
- Furcation involvement.
- Pockets 5mm+.
- Furcation involvement.
What toothpaste do we advise to radiotherapy patients? (5)
- ESSENTIAL.
- 2800ppm or 5000ppm.
- Advise 2x daily use.
- Supplement with varnish and mouthwash.
- Caution if children in household.
What are fluoride trays and how do you advise the patient to wear them (4)?
- CUSTOM made trays, upper and lower.
- Fill with duraphat toothpaste or fluoride mousse.
- Minimum 5 minutes daily wear.
When should hygiene phase therapy be perfomed in radiotherapy patients? What is its benefit?
- ESSENTIAL.
- BEFORE and AFTER radiotherapy treatment.
- Tie in with duraphat varnish application.
- May LESSEN SEVERITY OF MUCOSITIS.
What is the benefit of the therabite (2) and how should it be used? Alternatives (2)?
- Use 7 times a day, 7 stretches, 7 seconds each.
- May increase mouth opening.
- Aid dental treatment.
- Alternatives: pat bite, spatulas.
What pharmaceuticals can be prescribed ? What are the used to treat?
- Pentoxyfylline.
- Vitamin E/ Tocopherol.
- PREVENT & MANAGEMENT ORN
- Use for trismus?
What drugs can be used to prevent/ damage ORN?
- Pentoxyfylline.
- Vitamin E.
How is hyperbaric oxygen hypothesised to help ORN (3)? 4 drawbacks?
- Hypoxia theory of ORN.
- Increases oxygen to damaged bone.
- Promotes healing.
- Drawbacks: poor evidence base, limited access, cost, compliance.
What does LLLT stand for?
Low level laser therapy.
6 key points regarding dental interventions and radiotherapy?
- Dental SCREENING pre-radiotherapy is essential.
- EXTRACT all teeth with dubious prognosis.
- Extract teeth AS EARLY AS POSSIBLE.
- If at risk of ORN, consider PREVENTIVE PROPHYLAXIS.
- make FLUORIDE TRAYS.
- Prescribe DURAPHAT TOOTHPASTE & MOUTHWASH.
3 types of chemotherapy?
- Neoadjuvant/ induction chemotherapy.
- Adjuvant chemotherapy with/without radiotherapy.
- Palliative chemotherapy.
How does chemotherapy work (5)?
- Uses drugs to KILL RAPIDLY DIVIDING CELLS.
- Interferes with mitosis, apoptosis and tumor cell DNA.
- Blunt tool.
3 chemotherapy drugs?
- Cisplatin
- Cetuximab
- TPF
7 general side effects of chemotherapy?
- Fatigue.
- Nausea.
- Vomiting and diarrhea.
- Skin rash.
- Hair loss.
- Thrombocytopenia.
- Neutropenia
4 oral side effects of chemotherapy?
- Mucositis.
- Infection
- Bleeding
- Temporary xerostomia
What is essential in cancer patients about to undergo chemotherapy?
- PRE TREATMENT DENTAL SCREENING ESSENTIAL.
- Extract hopeless teeth.
4 things we can do for mucositis?
- Soft splints.
- Caphosol.
- Low level laser therapy?
- Hygiene phase therapy BEFORE chemotherapy starts.
When should hygiene phase therapy be perfomed in chemotherapy patients? What is its benefit?
- BEFORE chemo starts.
- May help lessen the severity of mucositis.
What should you do if you find an oral infection in a chemotherapy patient (3)?
- Recognize it.
- Swab it/ oral rinse.
- Prescribe accordingly.
What must you do to manage bleeding in chemotherapy patients (2)?
- Be prepared for it.
- Check bloods (FBC, coagulation screen) before invasive dental treatment.
4 key points regarding dental interventions and chemotherapy?
- Dental SCREENING pre-chemotherapy is essential.
- EXTRACT all teeth with dubious prognosis.
- Extract teeth AS EARLY AS POSSIBLE.
- Check bloods if extractions needed during/ soon after chemotherapy.
5 most common abused drugs in Scotland?
- Cannabis
- Cocaine
- Ecstasy
- Amphetamines
- Heroin (least common - accounts for 1%)
Cocaine prevalence in Scotland?
- Scotland has highest rate of cocaine use in the world.
- 1 in 10 scottish teenagers over 16
What happens when you mix cocaine and alcohol?
- Cocaethylene forms.
- can consume x3 alcohol without becoming incapacitated.
What happens when you have cocaethylene in your system?
x24 more likely to have a heart attack.
Why is recreational drug use an important part of social history?
MI can result in pain in mandible.
What to ask patient regarding recreational drug use in social history (3)?
What did they use.
How much used.
When used.
What are legal highs?
- Bath salts (not designed for human consumption).
5 stimulants?
- Caffeine
- Nicotine
- Cocaine
- Amphetamine
- Ecstasy
5 depressants?
- Alcohol
- Solvents
- Heroin
- Morphine
- Benzodiazepines
3 Hallucinogenics?
- LSD
- Magic mushroom
- Cannabis
Deaths from drugs, alcohol, smoking?
- 500 deaths/year from drug abuse.
- 5-25,000 deaths/year from alcohol.
- 100,000 deaths/year from smoking
2 acts regarding drugs in the UK?
- The medicines act 1968
- The misuse of drugs act 1971
Class A drugs according to misuse of drugs act 1971?
- Heroine.
- Cocaine (including crack).
- Methamphetamine.
- Ecstasy.
- Methadone
2 reasons methadone is used prescribed?
- Substitute replacement programs (replace heroin)
- Cancer (opioid analgesic).
Class B drugs according to misuse of drugs act 1971?
- Cannabis
- Amphetamine
Class C drugs according to misuse of drugs act 1971?
- Benzodiazepines.
- Ketamine.
- Anabolic steroids (roid rage).
What is heroin?
- Synthetic opiate
- Chemical derivative of morphine (principle ingredient of opium).
- 4 times more potent than morphine
6 positive of opiates?
- Initial euphoria.
- removal of tension
- tranquility
- sense of control
- detachment from worries, fears
- analgesia
8 negatives of opiates?
- Itching.
- Flushing
- Myosis
- Appetite suppression
- Slurred speech.
- Slow gait.
- Depression.
- Constipation
5 medical complications of injecting drugs?
- BBVs.
- DVTs.
- Abscesses.
- Collapsed veins
- Amputations
Health problems related to RISKY BEHAVIOUR due to drug use (5)?
- Unwanted pregnancy.
- STDs
- BBVs
- Assault
- Death
Mental health problems related to drug use (5)?
- Paranoia
- Schizophrenia
- Depression
- Bulimia/ anorexia
- Bipolar
Fould’s classification of mental health?
- Organic (ex. dementia plaques).
- Neurosis
- Psychosis
- Personality disorder
- Eating disorder
Neurosis?
- FUNCTIONAL mental disorder without delusions or hallucinations. Behavior is not outwith socially acceptable.
- Contact RETAINED with reality.
- Anxiety, depression
Psychosis?
- DELUSIONS and HALLUCINATIONS common.
- Changes in PERSONALITY, THOUGHTS, STRANGE BEHAVIOR.
- Difficulty carrying out daily activities
- Contact with reality LOST.
- Ex. Bipolar, schizophrenia
Delusion?
False firmly held believe that you cannot shake the patient off from.
What is schizophrenia? What does it cause (4)?
- Most severe form of FUNCTIONAL psychosis.
- THOUGHT & EMOTION disorder.
- Distortion of thinking and perception.
- CHARACTERISTIC DELUSIONS
- AUDITORY HALLUCINATIONS (often threatening/ derogatory).
What is the most severe form of functional psychosis?
Schizophrenia
3 types of eating disorders?
- Anorexia nervosa.
- Bulimia nervosa.
- Pica
What is anorexia? 4 oral effects?
- Altered perception of body image.
- Ulcers, dry mouth, infections, bleeding.
What is bulimia? 2 oral effects?
- Normal weight (binge/ vomit).
- Comfort eating - stress reaction?
- Dental erosion, esophageal stricture.
What is Pica? 3 dental effects?
- Persistent and compuslve cravings for NON-FOODS.
- Fracture TEETH, DENTURES, BRACES.
Oral problems in drug users (12)?
- Poor OH.
- Xerostomia
- Sugar craving
- High caries rate
- Poor perio condition
- Smoking common
- ANUG common
- Poor aesthetics
- Low self esteem
- Trauma common
- Poor attendance
- Dental anxiety
3 ways to break the cycle of drug abuse?
- Harm reduction (clean injecting material).
- Substitution (methadone instead of heroin).
- Prison.
opiod?
Synthetic opiate analgesic (ex. methadone).
How does methadone work? How is it administered?
- Action on the CNS.
- Oral administration - absorbed from BUCCAL MUCOSA and STOMACH.
- Continous occupancy of Mu opiod receptors.
- Stabilizes neurochemistry.
- Can lead to cessation of IV drug use.
Drug related effects on oral health (4)?
- Xerostomia
- Bruxism/ habits
- Sugar craving
- Sugar in medication (methadone).
3 effects of methadone on dental health?
- High sugar content in syrup 50% so HIGH CARIES RISK.
- Often methadone held in mouth to increase absorption from buccal mucosa HIGH CARIES RISK.
- Opiate analgesic therefore DECREASES SALIVARY FLOW so HIGH CARIES RISK.
Pathognomonic sign of heroin use?
- Circumferential caries that is very dark.
Cannabis related leukoplakia, POTENTIALLY MALIGNANT.
