Special Care Flashcards
What age are you able to make legally binding decisions for yourself in Scotland?
Age 16
what is the legal definition of incapacity?
the inability of an adult (16 or older) to enter legally binding contracts
AMCUR
What is meant by the term having incapacity?
being incapable of
- acting
- making a decision
- communicating decision
- understanding decision
- retaining memory of decision
What is a proxy?
A suitable adult substitute decision maker for someone without capacity
True or false: a welfare power of attorney can consent for dental treatment
TRUE
Briefly outline power of attorney
- granted while a patient who has capacity for someone to act on their behalf should the need arise
- no expiry date
- can be more than one person
- often trusted family member or friend
What is a continuing (financial) power of attorney?
- only covers financial affairs and property
- cannot consent to dental treatment
Briefly outline guardianship orders
- court appointed person to make designs on behalf of adult with incapacity
- appointed by Sheriff after adult has lost capacity
- requires 2 medical reports
- usually appointed for 3 years
give a common example of when a guardianship order would be used
Parents of a child with a learning disability may need to apply for guardianship after turning 16
Who can consent for dental treatment?
- patients with capacity
- welfare power of attorney
- welfare guardians
- medical and dental practitioners under section 47 of adults with incapacity act (requires a short course before being able to do this as a dentist)
What is meant by ‘impairment’
- any loss or abnormality of psychological, physiological or anatomical structure or function
- occurs at the level of organ or system function
what is meant by the term ‘disability’?
- Any restriction or lack of ability to perform an activity in the manner or within range considered normal for human being
- actively restricted by impairment
- concerned with functional performance or activity
What is meant by the term ‘handicap’?
A disadvantage for a given individual
- resulting from an impairment or disability
- that limits or prevents fulfilment of a role that would be considered normal for that individual
What law protects people from discrimination in the workplace and wider society?
the equality act 2010
Briefly outline the inverse care law
The availability of good medical care usually varies inversely with the need for it in the population served
What are the barriers to care?
- Accessibility
- accommodation
- affordability
- acceptability
- availability
Management of a patient on warfarin prior to extraction
check INR no more than 24 hours before procedure (72 hours if patient stably anti coagulated)
if INR below 4 - treeat
delay if over 4
Examples of DOACs
- rivaroxiban
- apixaban
- edogaban
- dabigatran
DOAC that needs to be taken twice daily
apixaban and dabigatran
Management of a patient on apixaban prior to extraction
miss morning dose
take dose 4 hours after haemostasis is achieved
Physical features of down syndrome
- growth failure
- short and broad hands
- broad flat face
- diminished muscle tone
- flat back of head
what is downs syndrome?
- neurodevelopmental disorder of genetic origin affecting chromosome 21
- 95% cases due to a full trisomy of chromosome 21
outline the social model of disability?
disability is caused by the way society is organised, rather than by a person’s impairment or difference
outline the medical model of disability
people are disabled by their impairments or differences
these impairments or differences should be ‘fixed’ or changed by medical and other treatments
medical features of Down syndrome
congenital heart defects
epilepsy
leukaemia
diabetes mellitus
intellectual impairment
hearing impairment
thyroid disease
Downs syndrome - intra-oral features
micro or macro dontia
class iii occlusion
AOB
large tongue
what is cerebral palsy?
a neurological condition that affect movement and coordination
Why might a patient with cerebral palsy have limited mouth opening?
it can affect the muscles that open and close the mouth and move the lips and tongue
Why does downs syndrome increase perio risk?
- impaired immune system
- unregulated production of inflammatory mediators
- reduced manual dexterity - OH
- enamel defects
5 principles of the 2000 adults with incapacity out
- benefit
- minimum necessary intervention
- take account of the wishes of the adult
- consultation with relevant others
- encourage adult to exercise ‘residual capacity’
aims of dental pre-assessmnet for cancer patient
- identifying existing oral disease and potential risk of disease
- remove infection and potential infection before start of cancer therapy
- prepare patient for expected side effects of cancer therapy
- establish adequate standard of oral hygiene to meet increasing challenges during cancer therapy
- develop plan for maintaining OH, providing preventative care, completing oral rehabilitation and follow up
- establish necessary multidisciplinary collaboration
potential dental issues than can occur during cancer treatment
- oral mucositis
- oral candida
- traumatic ulceraion
- reactivate of HSV
- xerostomia
- trismus
- dental erosion
- caries
- periodontal disease
risk factors for osteoradionecrosis
- total radiation dose exceeded 60Gy
- dose fraction was large with a high number of fractions
- local trauma as a result of tooth extraction, uncontrolled periodontitis or ill-fitting denture
- person is malnourished
- pt is immunodefiecient
Radiation caries pattern
- V shaped
- around cervical margin
prevention and management of oral mucositis
- calcium phosphate mouth rinse
- mucoadhesive oral rinse
- soluble aspirin
- zinc supplements
- aloe vera
- cryotherapy
- Manuka honey
- intensive oral hygiene
- 2% lidocaine mouthwash prior to eating
- tea tree oil mouthwash
- morphine and opioid analgesics
What is dementia?
an acquired progressive loss of cognitive functions, intellectual and social abilities
dementia characteristics/signs
amnesia
- especially for recent events
inability to concentrate
disorientation in time, place or person
intellectual impairment
also commonly accompanied by deterioration in
- emotional control
- social behaviour
- motivation
types of dementia
Alzheimers
Vascular
Frontotemporal
dementia with lewy bodies
How is Alzheimers caused?
reduction in size of the Cortex
Plaques (deposits of beta-amyloid protein) build up in spaces between nerve cells
tangles (twisted fibres of tau protein) built up inside cells
How is vascular dementia caused?
reduced blood flow to the brain, which damages and eventually kills the brain cells
can develop as a result of
- small vessel disease
- a single large stroke
- lots of mini strokes
dementia with Lewy bodies is caused by…
deposits of an abnormal protein called Lewy bodies inside brain cells
- also found in people with Parkinson’s
dementia risk factors
age
gender
genetic background
medical history
lifestyle
give at least 3 features of a dementia friendly healthcare environment
reception desk visible from entrance door
ceilings, floors and floor coverings should be acoustically absorbent to support audible communication
colour and tone of walls should be distinctive from flooring
colour and tone of furniture should be distinctive from flooring
avoid non-essential signs
any signage should be at eye level with simple clear use of text and colour
ensure good levels of natural light
any staff only or locked rooms should be coloured the same as walls to avoid attention
risk factors for drug misuse and addiction
men 2x as likely
genetics
socioeconomic factors
environmental:
- home and family, friends and acquaintances that do drugs
personality
- low self esteem
- stress
availability
coexisting mental problems
peer pressure
physical and sexual abuse
early exposure to drugs
You have an addiction problem. What should you do?
put interest of your patient first
consult senior colleague to ask for advice and support
- document encounter if you are the colleague
are you safe to practice?
support groups
- British doctors and dentists group
engage with medical services
one of your patient’s is an alcoholic, what considerations would you make in regards to treating them?
morning appointments
- least likely time to be under the influence
patient may have poly-substance misuse including smoking
sedatives have an addictive effect with alcohol
GA best avoided
- increased risk of vomiting and inhalation of vomit
- may be resistant to GA
many recovering addicts may be on disulfiram (Antabuse)
- psychoitic reaction with metronidazole
alcohol abuse potential dental implications
advanced caries, periodontal disease and NCTSL
angular stomatitis
RAS
increased risk of leukoplakia and oral cancer
dialysis
erosion
nocturnal bruxism
dry mouth secondary to dehydration and vomiting
considerations to take prior to an extraction on an alcoholic
impaired wound healing
liver cirrhosis = bleeding risk
avoid use of aspirin and NSAIDs
- paracetamol safest analgesic
dental implications of opiate abuse
trauma
infective endocarditis
enhances sedation agents
impaired drug metabolism
oral neglect
methadone - dental implications
high sugar content
- 5ml methadone = 2.5mg sugar
- sugar free prep available
caries rate higher in methadone users
dental advice for methadone users
use a straw
drink water after consumption
- prevents regurgitation
don’t brush teeth immediately after
engage with dental services
prevention
sugar free suspension available
opioids - dental considerations
suboptimal oral hygiene and self care
use leads to salivary hypofunction
- xerostomia
- caries
- burning mouth
- taste impairment
smooth surface, buccal and cervical caries often present prior to beginning methadone therapy
anxiety and opioid use can reduce effectivenesss of LA
injecting drug users at greater risk of BBV and endocarditis
can cause thrombocytopenia putting patients at risk of post op bleeding
- especially if liver function impaired
patient smokes cannabis and is due to come in for sedation appointment. what advice should you give prior to appointment?
patients should be advised to not use cannabis for at least 72 hours before treatment under conscious sedation in order to reduce the likelihood of drug interactions and unpredictable sedation quality
cocaine dental and facial consequences
bruxism, clenching and NCTSL
gingival erosions, retraction and ulcerative lesions at the site of application - owing to rubbing of powder topically
- resolve upon abstaining from use within 2weeks to 18 months
chronic sinusitis
nasal crusting
epistaxis (nose bleeds)
higher periodontitis risk
use of powder intramurally = decrease in saliva pH
enhances body’s response to adrenaline
links between cocaine use and development of cluster headaches
treating cocaine users in practice - considerations
defer dental treatment for 6-24 hours after last administration of cocaine
administration of LA after recent cocaine use can lead to acute increase in blood pressure
- use of lidocaine may increase chance of convulsions
long term physical effects of cocaine use
palatal and nasal septum perforation due to acidic nature and vasoconstrictor
methamphetamine use dental implications
poor oH
- meth mouth = rampant caries
bruxism, clenching and NCTSL
xerostomia
risk of osteonecrosis of mandible
Patients at low risk for MRONJ
patients being treated for osteoporosis or other non-malignant diseases of bone with bisphosphonates for less than 5 years, who are not concurrently being treated with systemic glucocorticoids
patients being treated for osteoporosis or other non-malignant diseases of bone with denosumab and are not being treated with systemic glucocorticoids
Patients at higher risk for MRONJ
patients being treated with bishosphonates for over 5 years
patients being treated with bisphosphonates or denosumab who are being concurrently treated with systemic glucocorticoids
patients being treated with anti-resorptive or anti-angiogenic drugs as part of the management of cancer
patients with previous MRONJ diagnosis
When would you refer a potential MRONJ patient post extraction?
If socket has not healed after 8 weeks
Patients at increased risk of infective endocarditis
acquired valvular heart disease with stenosis or regurgitation
hypertrophic cardiomyopathy
previous infective endocarditis
structural congenital heart disease
valve replacement
Infective endocarditis - sub group requiring special consideration
If a patient required antibiotic prophylaxis prior to treatment, what would you be bale to give them?
3g oral powder sachet Amoxicillin, 1 hour before procedure
or (if allergic to penicillin)
600mg (2x 300mg capsules) Clindamycin, 1 hour before procedure
Give examples of invasive dental procedures
give examples of non-invasive dental procures
signs of early stage dementia
loss of short term memory
confusion
poor judgement
anxiety, agitation or distress over perceived changes
inability to manage everyday tasks
communication problems
signs of middle stage dementia
more support required
- reminders to eat, wash, dress etc
increasing;y forgetful
- may fail to recognise people
distress
- aggression, anger, mood changes, frustration
risk of wandering and getting lost
may experience hallucinations, throw-back memories
signs of late stage dementia
inability to recognise familiar objects, surroundings or people
- may be flashes of recognition
increasing physical frailty
- may start to shuffle or walk unsteadily
difficulty eating and sometimes swallowing
- weight loss
incontinence and gradual loss of speech
