Special Care Dentistry Flashcards
what is impairment?
Any loss or abnormality of psychological, physiological, or anatomical structure or function.
what is disability?
Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.
Disability is concerned with functional performance or activity, affecting the whole person.
Disability is activity restricted by impairment.
what is handicap?
A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual.
describe equality act 2010?
The Equality Act 2010 legally protects people from discrimination in the workplace and in wider society.
The Act provides a legal framework to protect the rights of individuals and advance equality of opportunity for all.
It provides Britain with a discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society.
what are some protected characteristics of equality act 2010?
age
disability
gender reassignment
marriage or civil partnership (in employment only)
pregnancy and maternity
race
religion or belief
sex
sexual orientation.
what is direct discrimination?
Treating someone with a protected characteristic less favourably than others
what is indirect discrimination?
Putting rules or arrangements in place that apply to everyone, but that put someone with a protected characteristic at an unfair disadvantage
what is harassment?
Unwanted behaviour linked to a protected characteristic that violates someone’s dignity or creates an offensive environment for them
what is victimisation?
Treating someone unfairly because they’ve complained about discrimination or harassment
what does the equality act do in regard to barriers?
The Equality Act 2010 places a legal duty on organisations, including dental services, to make reasonable adjustments to reduce the barriers that may affect people accessing care
Change the way things are done
Change a physical feature
Provide extra aids or services
what are the 5 domains to overcoming barriers?
Accessibility
Accommodation
Affordability
Acceptability
Availability
what is ‘availability’ domain?
A lack of suitable available services can discourage health seeking behaviours
The nature and volume of treatment required in a region must be evaluated ensuring care is available using public funds suitably; this challenge affects both general and specialist services.
what is ‘accommodation’ domain?
accommodation refers to the relationship between the organisation of services and pt’s needs
could include barriers created by poor transitional arrangements between services or timing or length of appointments
what is ‘affordability’ domain?
One of the largest barriers to healthcare for people with disabilities is cost.
what is ‘acceptability’ domain?
The nature of services themselves, even when adjustments are made, must be acceptable for people with disabilities.
Every individual may have their own view on what is deemed acceptable, therefore when deciding on a treatment plan for a patient, it is important that the clinician adopts a person-centred approach whilst consulting to seek their views and values.
what is accessibility domain?
The appropriate service for dental care may be geographically far from where somebody lives,
In terms of physically and practically accessing care, people with disabilities may need specific facilities.
Those with a physical disability may be dependent on others for many or all activities of daily living including oral care are protected by what act?
Disability Discrimination Act
what are upstream approaches to special care?
Policies aimed at social inclusion and better access to education and employment opportunities
Better insurance policies for this group including specific national dental insurance criteria and
Eligibility for free or subsidised dental care.
what are downstream actions to SCD?
Design of a regional dental care infrastructure to increase access to dental care for disabled people.
what is Adult’s with Incapacity (Scotland) Act 2000?
The Adults with Incapacity (Scotland) Act 2000 was introduced to protect individuals (aged 16 and over) who lack capacity to make some or all decisions for themselves and to support their families and carers in managing and safeguarding the individual’s welfare and finances.
what is an adult with incapacity incapable of?
acting; or
making decision; or
communicating decisions; or
understanding decisions; or
retaining the memory of decisions.
what is Patient Right’s Act?
supports the Scottish Government’s plans for a high-quality NHS that respects the rights of patients as well as their carers and those who deliver NHS services.
Included in the act was the establishment of a Patient Advice and Support Service (PASS). This service provides free, accessible and confidential information, advice and support to patients, their carers and families about NHS healthcare.
what does the patient’s right act give right to?
considers their needs;
considers what would most benefit their health and wellbeing;
encourages them to take part in decisions about their health and wellbeing, and gives them the information and support to do so
what is The Mental Health (Care and Treatment) (Scotland) Act 2003?
Applies to people who have a “mental disorder”
This is defined under the Act and includes any mental illness, personality disorder or learning disability
what is an emergency detention certificate?
An emergency detention certificate allows a person to be held in hospital for up to 72 hours while their condition is assessed.
what is a compulsory treatment order?
A compulsory treatment order (CTO) allows for a person to be treated for their mental illness.
The CTO will set out a number of conditions that you will need to comply with. These conditions will depend on whether you have to stay in hospital or are in the community.
what is sensory impairment?
When one or more of a person’s senses is no longer normal
A person does not have to have full loss of a sense to be sensory impaired
what is visual impairment classification?
Mild – presenting visual acuity worse than 6/12
Moderate – presenting visual acuity worse than 6/18
Severe – presenting visual acuity worse than 6/60
Blindness – presenting visual acuity worse than 3/60
what is cataract?
Cataract is clouding of the lens of the eye which prevents clear vision.
Majority related to ageing process
Occasionally children can be born with the condition
Cataract may develop after eye injuries, inflammation, and some other eye diseases.
what is age-related macular degeneration?
Age-related macular degeneration (AMD) is a condition affecting older people
Involves the loss of the person’s central field of vision.
It occurs when the macular (or central) retina develops degenerative lesions.
The macula, a tiny area within the retina at the back of the eye.
The cells of the macula are photoreceptor cells, which means they’re sensitive to light and play a vital role in our ability to see details and colour
The cells become damaged and scarred.
It is thought that circulatory insufficiency, with reduction in the blood flow to the macular area, also plays a part.
Several forms of AMD exist.
what is wet macular degeneration?
Causes severe sight loss in a matter of months
can develop very rapidly, resulting in more sudden sight loss.
Growth of new vessels under retina which then break and leak into the macula
Occurs when unhealthy new blood vessels begin to grow under the macula and leak blood and fluid (this is why it’s called ‘wet’ macular degeneration), which then causes scarring to develop within the macula cells.
what is dry macular degeneration?
Bilateral condition
90% of cases
Thought to have a hereditary element and myopia may be a predisposing factor.
Gradual loss of central vision.
Person becomes unable to recognise people because they cannot see their faces clearly, cannot see bus numbers etc.
Layers of the macula become progressively thinner, causing it to function less effectively.
what is glaucoma?
Bilateral condition
90% of cases
Thought to have a hereditary element and myopia may be a predisposing factor.
Gradual loss of central vision.
Person becomes unable to recognise people because they cannot see their faces clearly, cannot see bus numbers etc.
Layers of the macula become progressively thinner, causing it to function less effectively.
what are 2 most common forms of glaucoma?
Primary open angle glaucoma (POAG)
Angle closure glaucoma (ACG),
what is primary open angle glaucoma?
Slow and insidious onset
Anterior chamber angle is open
Caused by the drainage channels in the eye becoming gradually clogged over time.
what is Angle closure glaucoma (ACG)?
Less common
More acute
Caused by the drainage in the eye becoming suddenly blocked,
Can raise the pressure inside the eye very quickly
what is diabetic retinopathy?
Diabetic retinopathy is composed of a characteristic group of lesions found in the retina of individuals having had diabetes mellitus for several years.
The abnormalities that characterise diabetic retinopathy occur in predictable progression with minor variations in the order of their appearance.
Diabetic retinopathy is considered to be the result of vascular changes in the retinal circulation.
In the early stages vascular occlusion and dilations occur.
It progresses into a proliferative retinopathy with the growth of new blood vessels.
Macular oedema (the thickening of the central part of the retina) can significantly decrease visual acuity.
Causes of Diabetic Retinopathy?
Over time, continuously high blood sugar levels can cause the blood vessels to become blocked orto leak.
This damages the retina and stops it from working, usually in 3 main stages:?
background retinopathy– tiny bulges develop in the blood vessels, which may bleed slightly but this doesn’t usually affect vision
pre-proliferative retinopathy– more severe and widespread changes affect the blood vessels, including more significant bleeding into the eye
proliferative retinopathy– scar tissue and new blood vessels, which are weak and bleed easily, develop on the retina. This can result in some loss of vision
Risk factors for diabetic retinopathy include
Duration of diabetes
Level of glycemia
Presence of high blood pressure
Dependence on insulin
Pregnancy
Levels of selected serum lipids
Nutritional
Genetic factors
what is Hemianopia?
Hemianopia is blindness in one half of the visual field.
This loss can be caused by a variety of medical conditions – stroke being the most common
Hemianopia is a functional defect which can affect the right or left side. Stroke patients with weakness of, for example, the right arm and leg have right sided poor vision.
Sight loss can be upper, lower, left or right.
how to maximise communication for people with visual impairment
Always identify yourself even in known surroundings
Always use names to identify people - especially in a group situation
Keep the visually impaired person informed of people moving around and/or leaving the room
Tell them what your doing before you do it – putting the chair back / LA / slow speed
what is hearing impairment?
A person who is not able to hear as well as someone with normal hearing – hearing thresholds of 25 dB or better in both ears – is said to have hearing loss.
Hearing loss may be mild, moderate, severe, or profound.
It can affect one ear or both ears, and leads to difficulty in hearing conversational speech or loud sounds.
severity classes of hearing impairment?
Mild 20 – 40 decibels
Moderate 41 – 70 decibels
Severe 71 – 95 decibels
Profound 95+ decibels
what is bmi?
BMI is defined as weight in kilograms divided by the square of the height in meters.
what are contributing factors to obesity?
Underlying health problems e.g. hypothyroidism in Down’s syndrome and eating issues such as Prader-Willi syndrome
A lack of energy
Difficulty with chewing or swallowing food or its taste or texture
Medications that can contribute to weight gain and changes to appetite e.g. steroid medication
Physical limitations that can reduce a person’s ability to exercise or have pain on movement (e.g. in cerebral palsy, rheumatoid arthritis
Lifestyle Factors: A lack of healthy food choices; accessible environments that enable exercise; resources and appropriate social support systems
what are difficult to give to bariatric pt’s?
Loss of anatomical landmarks is possible. Access issues with large cheeks, tongue etc.
ID blocks may be difficult. Alternative techniques may need to be considered such as the Gow-Gates or intraligamentary techniques.
Consider use of a ‘Lax’ tongue retractor if a dental mirror is insufficient for soft tissue retraction
what position would you treat bariatric pt’s?
May have to be treated semi-supine or sitting upright – practitioners need to be careful with their posture.
what is more challenging when treating bariatric pts?
Intra-oral radiography can be more challenging due to increased soft tissues.
OPT can be difficult or even impossible if the machine is unable to accommodate the patient’s size.
what can long procedures of bariatric pts lead to?
Long procedures can lead to acute leg oedema, cellulitis, Compartment Syndrome and pressure sores.
what can excessive fat in tissues also affect?
pharmacological absorption of a drug
dental implications of bariatric pts?
Caries
Wound Healing:
Extractions, Surgical Periodontal Treatment, Biopsies
Bariatric patients are more likely to have reduced immune function leading to delayed wound healing.
Tooth-wear:
Erosive tooth wear is more likely - increased prevalence of GORD in bariatric persons.
Increased incidence of oesophageal reflux, in particular in those having gastric banding, causing acid erosion.
what is most appropriate form of sedation in bariatric patients?
inhalation sedation
what’s a contraindication to IV sedation?
Obese adults are at risk of sleep apnoea - a contraindication to dental sedation in a primary care setting.
why are bariatric adults not suitable for conscious sedation?
Bariatric adults are not suitable for conscious sedation in a standard dental clinic due to difficulty placing cannula.
negative consequences of bariatric surgery?
Negative consequences e.g. nutritional deficiencies,“dumping” syndrome and eating disorders, such as anorexia, bulimia and compulsive eating.
Correlationwith oral problems, such as periodontal disease, increase in dental caries, hyposalivation, ulcers, dentine sensitivity and halitosis.
Following surgery patients are advised to divide food intake into 4-6 meals throughout the day, chewing slowly.
Higher frequency and prolonged meal times = increase risk of caries as sugary items are ingested.
At increased risk of dental erosion due to the common side effect of reflux and vomiting
what are messages GDP must give to pts who have done bariatric surgery?
- Ingestion of a healthy, balanced diet (reduction in thequantity and frequency of foods and beverages with added sugar, avoid eating at night);
- Adequate oral hygiene.
- Stimulate salivary flow to avoid dry mouth (increase water ingestion by taking a bottle with you and drinking small sips) +/- artificial saliva;
- Increase the consumption of foods rich in fibre;
- Chew gum without sugar, but only two month after surgery;
- To avoid halitosis or coated tongue, brush the tongue or use a tongue scraper;
- Take care to avoid tooth wear (diminish consumption of acidic foods, such as citrus fruit, vinegar and soft drinks);
- Drink soft drinks or fruit juices through a straw to minimize contact with the teeth; in case of ingesting soft drinks, never brush right afterwards, but perform mouth rinsing with water;
- Never brush the teeth after episodes of vomiting or reflux, if you are not at home, perform mouth rinsing with water or chew gum without sugar; if you are at home: perform mouth rinsing with sodium bicarbonate (one teaspoon in half a glass of water, to alkalinize the oral medium, and wait for half an hour before brushing your teeth).
- Provide topical fluoride varnish and OHI as required
what could a gdp do to control obesity?
Oral jaw wiring (OJW) or maxilla-mandibular fixation (MMF) have been applied in an effort to control obesity
Describe the key features of your General Dental Practice design and the facilities you
must consider providing to allow those with limited mobility, or a physical impairment, to
access your General Dental Practice?
i) Access to the building
Physical access is a barrier to care.
- disabled parking - width of spaces
- kerb/pavement
- path into building - tiles which could be broken/slippery when wet?
- ground level access or if stairs:
- ramp access
- grab rail
- lift
a) Describe the key features of your General Dental Practice design and the facilities you
must consider providing to allow those with limited mobility, or a physical impairment, to
access your General Dental Practice?
ii) Access to the dental surgery
Physical access is a barrier to care.
- height of reception desk
- adequate space for wheel in waiting area
- door width
- obstacles - keep corridor clear
- level threshold
- door opening position and door handles
- toilet that is accessible to those in a wheelchair
- training for reception staff - first point of contact
Do you feel you have a responsibility to facilitate access to healthcare facilities for
patients?
No matter what our personal beliefs maybe, Dentistry is a profession where the moral and
ethical principles of equality and diversity must be embraced to ensure access and fair
treatment for all people. We have a responsibility to enable people to receive the highest
quality of care we are capable of. Just because someone lives with impairment or disability does
not mean they should be subject to inequality, inequity, discrimination or prejudice.
c) Are you aware of any legislative framework which exists to enable the access and
provision of care for all individuals and groups of people?
i) List the key pieces of legislation
ii) Provide a brief overview of their impact on:
You as a healthcare provider
The patient
Legal framework:
The Equality Act 2010: Legal framework to protect those from discrimination for reason of:
disability, race, sex, sexual orientation, religion, age, pregnancy, transsexuality Brings together
multiple different Acts including The Disability Discrimination Act 1995 to make the law simpler
and clearer.
For disability the new legislation improves protection by:
- Concept of reasonable adjustment – changes how things are done, changes to
buildings, provision of aids - Making it easier for someone to show that they have difficulty carrying out their
day-to-day activities – ability to access financial support - Protecting from indirect discrimination
- Positive action - when something is done specifically to help someone who has a
protected characteristic – e.g., encouraging or training people to apply for jobs or
take part in an activity in which people with that characteristic are underrepresented. - Employers can no longer ask direct questions about disability (unless there is good
reason)
d) The concept of reasonable adjustment is present within the legal framework
i) Attempt to define and explain the concept of reasonable adjustments
A Reasonable Adjustment is any step which can be reasonably taken to prevent any provision,
criterion or practice, or any physical feature of its premises, from putting a disabled person at a
disadvantage in comparison with a non-disabled person.
Factors to be weighed up in determining reasonableness are:
how effective the adjustment is in preventing the disadvantage
how practical it is
the cost of making the adjustment
the potential disruption caused
the time, effort and resources involved
number of resources already spent on making other adjustments
the availability of financial or other help.
Cost can be a major factor when deciding whether an adjustment is reasonable. The majority of
adjustments are relatively inexpensive if not free
ii) Suggest one example of a reasonable adjustment which a dentist might make to a dental practice
- Providing a ramp in addition to the stairs up into the practice
iii) Suggest one example of an adjustment which would be unreasonable to make to a dental
practice
- A lift in a practice which is in an old tenement building
iv) What would you do if you were unable to make any reasonable adjustments to enable Mrs
Smith to access your practice?
If you in your practice unable to allow a patient to access your surgery you have a responsibility
to facilitate care for them at a place which can. e) Mrs Johnson is unable to transfer to the
dental chair by herself. What feasible options are available to aid her transfer? Discuss their
benefits and weaknesses.
e) Mrs Johnson is unable to transfer to the dental chair by herself.
Consider the feasible options which are available to aid her transfer and list positives and
limitations.
1) Hoist
positives:
- Can be used for non-weight bearing individuals
- Allows transfer to dental chair, safest management environment
limitations:
- Additional training required
- Additional equipment
2) Banana Board
positives:
- Self transfer
limitations:
- Generally, Requires leg break chair
3) Reclining Wheelchair
positives:
- No need to transfer
limitations:
- Dentist access challenging
- Management of medical emergencies
- Expensive equipment
4) Turn Table
positives:
- Promotes involvement of patient
limitations:
- Additional equipment
5) Wheelchair recliner
positives:
- No need to transfer
- No cost to dentist
- Access in GDP
limitations:
- Dentist access challenging
- Management of medical emergencies
6) Stand Aid
positives:
- Promotes involvement of patient
limitations:
- Must be able to weight bear
- Specialist equipment
Question 2:
Mrs. Johnson is now seated in the dental chair. This is her first appointment and you are
required to complete a new patient history.
a) How do you take a history?
Follow the same principles as for any other patient. However, perhaps more time is
required find out about her medical condition.
Asking questions during the history taking process is essential to allow you to build up
picture of the patient.
Question 2:
Mrs. Johnson is now seated in the dental chair. This is her first appointment and you are
required to complete a new patient history.
b) Why is the information important?
To obtain the necessary details to inform your clinical assessment and management plan
Question 2:
Mrs. Johnson is now seated in the dental chair. This is her first appointment and you are
required to complete a new patient history.
c) Are there any further questions you would wish to ask this lady?
Further questioning for this lady may include:
C/O and HPC : more detailed pain history –
SOCRATES pain assessment ?
MH: stability of her condition, medications, prognosis
SH: how does she travel to the clinic, timings of treatment (not early appointments – a best time
of the day?)
Dry mouth – this lady has a diagnosis of Rheumatoid arthritis. Whilst there are multiple causes for dry mouth, the risk of Sjogren’s is particularly pertinent she has an already existing
autoimmune condition.
Consider asking about: Symptoms: Occular and oral symptoms
Signs: Tendency of the mucosa to stick to a dental mirror or tongue spatula; food residues
within the oral cavity; frothiness of saliva, particularly in the lower sulcular reflection; and the absence of frank salivation from major gland duct orifices.
The tongue may develop a characteristic appearance: a lobulated, red surface with partial or complete depapillation. Salivary gland enlargement
American-European Consensus Group Criteria. Revised international classification criteria for
Sjögren’s syndrome (SEE IT ON RHEUMATOLOGY GUIDANCE SHEET)
a) Briefly describe her medical diagnoses:
i) Rheumatoid Arthritis
Rheumatoid arthritis, or RA, is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful
swelling) in the affected parts of the body.
RA mainly attacks the joints, usually many joints at once. RA commonly affects joints in the hands,
wrists, and knees. In a joint with RA, the lining of the joint becomes inflamed, causing damage to
joint tissue. This tissue damage can cause long-lasting or chronic pain, unsteadiness (lack of balance), and deformity (misshapenness).
RA can also affect other tissues throughout the body and cause problems in organs such as the
lungs, heart, and eyes.
What are the signs and symptoms of RA?
With RA, there are times when symptoms get worse, known as flares, and times when symptoms get better, known as remission.
Signs and symptoms of RA include:
Pain or aching in more than one joint
Stiffness in more than one joint
Tenderness and swelling in more than one joint
The same symptoms on both sides of the body (such as in both hands and both knees)
Weight loss
Fever
Fatigue or tiredness
Weakness
What causes RA?
RA is the result of an immune response in which the body’s immune system attacks its own healthy
cells. The specific causes of RA are unknown, but some factors can increase the risk of developing
the disease.
What are the risk factors for RA?
Characteristics that increase risk
Age. RA can begin at any age, but the likelihood increases with age. The onset of RA is
highest among adults in their sixties.
Sex. New cases of RA are typically two-to-three times higher in women than men.
Genetics/inherited traits. People born with specific genes are more likely to develop RA.
These genes, called HLA (human leukocyte antigen) class II genotypes, can also make your
arthritis worse. The risk of RA may be highest when people with these genes are exposed to
environmental factors like smoking or when a person is obese.
Smoking. Multiple studies show that cigarette smoking increases a person’s risk of
developing RA and can make the disease worse.
History of live births. Women who have never given birth may be at greater risk of
developing RA.
Early Life Exposures. Some early life exposures may increase risk of developing RA in
adulthood. For example, one study found that children whose mothers smoked had double
the risk of developing RA as adults. Children of lower income parents are at increased risk of
developing RA as adults.
Obesity. Being obese can increase the risk of developing RA. Studies examining the role of
obesity also found that the more overweight a person was, the higher his or her risk of
developing RA became.
How is RA diagnosed?
RA is diagnosed by reviewing symptoms, conducting a physical examination, and doing X-rays and lab tests. It’s best to diagnose RA early—within 6 months of the onset of symptoms—so that people with the disease can begin treatment to slow or stop disease progression (for example, damage to joints). Diagnosis and effective treatments, particularly treatment to suppress or control inflammation, can help reduce the damaging effects of RA.
what is RA treatment?
RA can be effectively treated and managed with medication(s) and self-management strategies.
Treatment for RA usually includes the use of medications that slow disease and prevent joint
deformity, called disease-modifying antirheumatic drugs (DMARDs); biological response modifiers (biologicals) are medications that are an effective second-line treatment. In addition to medications, people can manage their RA with self-management strategies proven to reduce pain and disability, allowing them to pursue the activities important to them. People with RA can relieve pain and improve joint function by learning to use five simple and effective arthritis management strategies.
What are the complications of RA?
Rheumatoid arthritis (RA) has many physical and social consequences and can lower quality of life. It can cause pain, disability, and premature death.
Premature heart disease. People with RA are also at a higher risk for developing other
chronic diseases such as heart disease and diabetes. To prevent people with RA from
developing heart disease, treatment of RA also focuses on reducing heart disease risk
factors. For example, doctors will advise patients with RA to stop smoking and lose weight.
Obesity. People with RA who are obese have an increased risk of developing heart disease
risk factors such as high blood pressure and high cholesterol. Being obese also increases risk
of developing chronic conditions such as heart disease and diabetes. Finally, people with RA
who are obese experience fewer benefits from their medical treatment compared with
those with RA who are not obese.
Employment. RA can make work difficult. Adults with RA are less likely to be employed than
those who do not have RA. As the disease gets worse, many people with RA find they cannot
do as much as they used to. Work loss among people with RA is highest among people
whose jobs are physically demanding. Work loss is lower among those in jobs with few
physical demands, or in jobs where they have influence over the job pace and activities.
a) Briefly describe her medical diagnoses:
ii) Osteoporosis
Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones).
Osteoporosis is a “silent” disease because you typically do not have symptoms, and you may not
even know you have the disease until you break a bone. Osteoporosis is the major cause of fractures in postmenopausal women and in older men. Fractures can occur in any bone but happen most often in bones of the hip, vertebrae in the spine, and wrist.
how to take steps to help prevent osteoporosis?
However, you can take steps to help prevent the disease and fractures by:
Staying physically active by participating in weight-bearing exercises such as walking.
Drinking alcohol in moderation.
Quitting smoking, or not starting if you don’t smoke.
Taking your medications, if prescribed, which can help prevent fractures in people who have
osteoporosis.
Eating a nutritious diet rich in calcium and vitamin D to help maintain good bone health.
Who Gets Osteoporosis?
Osteoporosis affects women and men of all races and ethnic groups. Osteoporosis can occur at any
age, although the risk for developing the disease increases as you get older. For many women, the
disease begins to develop a year or two before menopause. Other factors to consider include:
Osteoporosis is most common in non-Hispanic white women and Asian women.
African American and Hispanic women have a lower risk of developing osteoporosis, but
they are still at significant risk.
Among men, osteoporosis is more common in non-Hispanic whites.
Certain medications, such as some cancer medications and glucocorticoid steroids, may increase the risk of developing osteoporosis.
Because more women get osteoporosis than men, many men think they are not at risk for the
disease. However, both older men and women from all backgrounds are at risk for osteoporosis.
Some children and teens develop a rare form of idiopathic juvenile osteoporosis. Doctors do not
know the cause; however, most children recover without treatment.
Causes of Osteoporosis
Osteoporosis occurs when too much bone mass is lost and changes occur in the structure of bone
tissue. Certain risk factors may lead to the development of osteoporosis or can increase the
likelihood that you will develop the disease.
Many people with osteoporosis have several risk factors, but others who develop osteoporosis may not have any specific risk factors. There are some risk factors that you cannot change, and others that you may be able to change. However, by understanding these factors, you may be able to prevent the disease and fractures.
Factors that may increase your risk for osteoporosis include?
Sex. Your chances of developing osteoporosis are greater if you are a woman. Women have lower
peak bone mass and smaller bones than men. However, men are still at risk, especially after the age of 70.
Age. As you age, bone loss happens more quickly, and new bone growth is slower. Over time, your
bones can weaken and your risk for osteoporosis increases.
Body size. Slender, thin-boned women and men are at greater risk to develop osteoporosis because they have less bone to lose compared to larger boned women and men.
Race. White and Asian women are at highest risk. African American and Mexican American women
have a lower risk. White men are at higher risk than African American and Mexican American men.
Family history. Researchers are finding that your risk for osteoporosis and fractures may increase if one of your parents has a history of osteoporosis or hip fracture.
Changes to hormones. Low levels of certain hormones can increase your chances of developing osteoporosis
Low oestrogen levels in women after menopause.
Low levels of oestrogen from the abnormal absence of menstrual periods in premenopausal women due to hormone disorders or extreme levels of physical activity.
Low levels of testosterone in men. Men with conditions that cause low testosterone are at risk for osteoporosis. However, the gradual decrease of testosterone with aging is probably not a major reason for loss of bone.
Diet. Beginning in childhood and into old age, a diet low in calcium and vitamin D can increase your risk for osteoporosis and fractures. Excessive dieting or poor protein intake may increase your risk for bone loss and osteoporosis.
Other medical conditions. Some medical conditions that you may be able to treat or manage can increase the risk of osteoporosis, such as other endocrine and hormonal diseases, gastrointestinal diseases, rheumatoid arthritis, certain types of cancer, HIV/AIDS, and anorexia nervosa.
Medications. Long-term use of certain medications may make you more likely to develop bone loss and osteoporosis, such as:
Glucocorticoids and adrenocorticotropic hormone, which treat various conditions, such as asthma and rheumatoid arthritis.
Antiepileptic medicines, which treat seizures and other neurological disorders.
Cancer medications, which use hormones to treat breast and prostate cancer.
Proton pump inhibitors, which lower stomach acid.
Selective serotonin reuptake inhibitors, which treat depression and anxiety.
Thiazolidinediones, which treat type II diabetes.
Lifestyle. A healthy lifestyle can be important for keeping bones strong. Factors that contribute to
bone loss include:
Low levels of physical activity and prolonged periods of inactivity can contribute to an increased rate of bone loss. They also leave you in poor physical condition, which can increase your risk of falling and breaking a bone.
Chronic heavy drinking of alcohol is a significant risk factor for osteoporosis. Studies indicate that smoking is a risk factor for osteoporosis and fracture. Researchers are still studying if the impact
Treatment of Osteoporosis?
The goals for treating osteoporosis are to slow or stop bone loss and to prevent fractures. Your
health care provider may recommend:
Proper nutrition.
Lifestyle changes.
Exercise.
Fall prevention to help prevent fractures.
Medications.
how is nutrition important in treating osteoporosis?
An important part of treating osteoporosis is eating a healthy, balanced diet, which includes:
Plenty of fruits and vegetables.
An appropriate number of calories for your age, height, and weight. Your health care provider or
doctor can help you determine the number of calories you need each day to maintain a healthy
weight.
Foods and liquids that include calcium, vitamin D, and protein. These helps minimize bone loss and
maintain overall health. However, it’s important to eat a diet rich in all nutrients to help protect and maintain bone health.
Calcium and Vitamin D
Calcium and vitamin D are important nutrients for preventing osteoporosis and helping bones reach peak bone mass. If you do not take in enough calcium, the body takes it from the bones, which can lead to bone loss. This can make bones weak and thin, leading to osteoporosis.
how is lifestyle important in treating osteoporosis?
In addition to a healthy diet, a healthy lifestyle is important for optimizing bone health. You should:
Avoid second hand smoke, and if you smoke, quit.
Drink alcohol in moderation, no more than one drink a day for women and no more than two drinks a day for men.
Visit your doctor for regular check-ups and ask about any factors that may affect your bone health or increase your chance of falling, such as medications or other medical conditions.
how is exercise important in treating osteoporosis?
Exercise is an important part of an osteoporosis treatment program. Research shows that the best physical activities for bone health include strength training or resistance training. Because bone is living tissue, during childhood and adulthood, exercise can make bones stronger. However, for older adults, exercise no longer increases bone mass. Instead, regular exercise can help older adults:
Build muscle mass and strength and improve coordination and balance. This can help lower your chance of falling.
Improve daily function and delay loss of independence.
Although exercise is beneficial for people with osteoporosis, it should not put any sudden or
excessive strain on your bones. If you have osteoporosis, you should avoid high-impact exercise
medications used in osteoporosis treatment?
Bisphosphonates. Several bisphosphonates are approved to help preserve bone density and strength and to treat osteoporosis. This type of drug works by slowing down bone loss, which can lower the chance of fractures.
Calcitonin. This medication is made from a hormone from the thyroid gland and is approved for the treatment of osteoporosis in postmenopausal women who cannot take or tolerate other medications for osteoporosis.
Oestrogen agonist/antagonist. An oestrogen agonist/antagonist, also known as a selective oestrogen receptor modulator (SERM), and tissue-selective oestrogen complex (TSEC), are both approved to treat and prevent osteoporosis in postmenopausal women. They are not oestrogen, but they have oestrogen-like effects on some tissues and oestrogen-blocking effects on other tissues. This action helps improve bone density, lowering the risk for some fractures.
Oestrogen and hormone therapy. Oestrogen and combined oestrogen and progestin (hormone
therapy) are approved to prevent osteoporosis and fractures in postmenopausal women. Because of potential side effects, researchers recommend that women use hormone therapy at the lowest dose, and for the shortest time, and if other medications are not helping. It is important to carefully consider the risks and benefits of oestrogen and hormone therapy for the treatment of osteoporosis.
Parathyroid hormone (PTH) analog and parathyroid hormone related protein (PTHrP) analog. PTH is a form of human parathyroid hormone that increases bone mass and is approved for postmenopausal women and men with osteoporosis who are at elevated risk for fracture. PTHrP is a medication that is also a form of parathyroid hormone. It is an injection and is usually prescribed for postmenopausal women who have severe osteoporosis and a history of multiple fractures.
RANK ligand (RANKL) inhibitor. This is an inhibitor that helps slow down bone loss and is approved to treat osteoporosis in:
Postmenopausal women or men with osteoporosis who are at elevated risk for fracture.
Men who have bone loss and are being treated for prostate cancer with medications that cause
bone loss.
Women who have bone loss and are being treated for breast cancer with medications that cause bone loss.
Men and women who do not respond to other types of osteoporosis treatment.
Sclerostin inhibitor. This is a medication that treats severe osteoporosis by blocking the effect of a protein, and helps the body increase new bone formation as well as slows down bone loss.
b) Consider the drug regime
i) What impact will they have on this person’s medical status?
ii) What impact may they have on your dental management?
Methotrexate
This is one of the non-biologic disease-modifying anti-rheumatic drugs (DMARDs). Methotrexate
inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines. It has anti-inflammatory and immunosuppressive effects.
This person will have regular routine bloodwork undertaken. This will allow us to evaluate their response to the drug and determine safety to manage the patient. You may wish these to be updated prior to undertaking dental treatment.
DMARD’s are not routinely stopped for dental treatment. Antibiotic prophylaxis is not routine, but maybe considered on a case by case basis for the most immunosuppressed of individuals.
For BIOLOGICAL DMARDs it is valuable to liaise with the prescribing clinician, as timing of treatment is normally important to avoid interruption to drug regimens and to maximise the immune status of
the patient.
Of note, this person should also be prescribed folic acid.
- Diclofenac
Non-steroidal anti-inflammatory medicine - Paracetamol
Analgesic and anti-pyrexic - Prednisolone – Short course when there is a flare of her symptoms, last flare 3 months ago
Prednisolone exerts predominantly glucocorticoid effects with minimal mineralocorticoid effects.
There has been a long and very controversial clinical and academic discussion surrounding the longterm use of glucocorticoid in patients and the need for additional steroid cover.
New guidance is currently being written; however, these are likely to support steroid cover for individuals who have taken 5mg prednisolone or equivalent for longer than 4 weeks and are thus at risk of HPA axis suppression (Sagar 2020) and adrenal crisis if physiologically stressed for instance during acute illness, surgery or other invasive procedures. It is likely that the guidance will suggest doubling the dose of steroid for this group ( up to a dose of 10-15mg of prednisolone, although this is currently uncertain).
For those with primary adrenal insufficiency, steroid cover should always be provided.
- Calichew
Calcium and vitamin D3 tablet
c) List your diagnosis?
- Dry mouth
- Chronic Periapical Periodontitis: 27,35, 37,45, and 46.
- Caries:17,16, 12,26,27,37,46,47,48
- Chronic generalized mild periodontitis – pocket charting required to confirm
Additional Findings:
Retained roots: 35 and 46
d) Can you suggest a differential diagnosis for the cause of her dry mouth?
- Medication related
- Disease – Sjogren’s Syndrome maybe worth exploring in this lady, or diabetes
- Dehydration
Question 4:
a) What are some of the factors that you would wish to take into account for this lady’s
short and long term dental care: short term:
Dougall et al suggest that we consider access in 4 ways:
Access to the building Previously discussed Access to the dental surgery Previously discussed Access to the dental chair Previously discussed Access to the mouth Rheumatoid Disease:
Effects on TMJ – level of opening.
Use of props? Role for sedation if muscular element?
Access to services: Appointment times, location and length. Transport.
Prevention: Mrs Johnsons oral hygiene is obviously very poor. Plaque is a risk factor for
multiple oral diseases. Mrs Johnson’s rheumatoid arthritis affects her manual dexterity.
She struggles to brush her teeth because she cannot hold a toothbrush.
Consider the volume and type of dental treatment – conducting 4 quadrant dentistry
requiring multiple extractions, restorations, in a patient with limited mouth opening for
a brief period of time may not be appropriate.
Treatment will have to planned considering access elements and drug regimens: (long
term steroids, immune status, new biological drugs)
Long term :
Stability of medical condition and dental disease rate
If Sjogrens consider the complications:
Tooth demineralization and caries
Gingival changes
Difficulty with chewing
Impairment of denture use
Swallowing difficulties
Oral malodour
Altered taste
Mucosal dryness and sensitivity
Oral infections (candidiasis and bacterial sialadenitis)
Malignant change - B Cell Lymphoma risk
Question 5 :
Can you formulate a Treatment Plan for this Lady?
Acute management: Manage pain and swelling
Stabilisation Phase:
1) Enhanced Prevention - OHI, Dietary Advice, Fluoride, Saliva Replacement/
Stimulation
2) PMPR if indicated on Pocket Charting
3) Attempt restoration of 17,16,12,26,48
4) Attempt Endodontics on 37 having assessed restorability(unlikely) – also consider
previous disease experience, motivation, ability to co-operate and long term dental and
general systemic prognosis
5) XLA 27, 28?, 35RR,45,46,47
6) Re-evaluate
Restorative Phase:
7) Consider provision of restoration of spaces and 37 if successful RCT cuspal coverage
8) Maintenance care
3 monthly review as high caries risk? Give some consideration to her ability to cooperate with treatment either for reasons of anxiety, medical, social and behavioural
reasons.
Question 6:
a) What measures would you put in place to maximise her preventative regime?
Provision of oral hygiene instruction Role of fluoride – Toothpaste, Varnish, Mouthwash is
controversial
