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Module 7 > Special Care Dentistry > Flashcards

Special Care Dentistry Flashcards

Topics covered : Patients with learning/physical disabilities and autism, AWI, Adult support and protection act and other key legislations, Dentistry for the medically compromised patient, anxiety management

1
Q

What reasons may make a patient unable to accept routine dental care therefore requiring referral to Special Care?

A

Due to:
- Physical Impairment
- Intellectual Impairment
- Medical Impairment
- Emotional Impairment
- Sensory Impairment
- Mental Impairment
- Social Impairment
- Or a combination of the above

This can involve:
- Learning/Physical disability
- Care for elderly
- Medically compromised
- Mental health issues
- Dentally anxious or phobic

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2
Q

Before treating any patient what 2 factors are important to consider?

A
  1. Is it safe?
    - e.g. MH and how it may impact their tx.
  2. Is it legal?
    - does the pt. understand
    - have we checked
    - do they have capacity
    - do we need consent from someone other than the pt.
    - who can we contact and how?
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3
Q

The 2010 Equality Act states that it is against the law to discriminate against someone because of?

A
  • Age
  • Disability
  • Gender reassignment
  • Marriage and Civil Partnership
  • Pregnancy and maternity
  • Race
  • Religion or belief
  • Sex
  • Sexual Orientation
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4
Q

A person with a disability is defined as having a physical/mental impairment.

Note the 6 most common impairments:

A
  1. Mobility
  2. Stamina/breathing/fatigue
  3. Dexterity
  4. Mental health
  5. Hearing
  6. Vision
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5
Q

List 6 causes of physical disabilities:

A
  1. Inherited or genetic
  2. Conditions present at birth
  3. Serious illness affecting the brain, nerves, or muscles
  4. Spinal cord injuries
  5. Brain injury
  6. Accidents
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6
Q

List 2 inherited/genetic disorders that can cause a physical disability:

A
  1. Osteogenesis imperfecta
  2. Dentinogenesis imperfecta
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7
Q

What physical affects can Osteogenesis imperfecta have on the patient?

A
  • Increased bone fractures
  • Collagen defects
  • Short stature
  • Hearing loss
  • Blue sclera
  • Dentinogenesis imperfecta
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8
Q

What physical affects can Dentinogenesis imperfecta have on the patient?

A
  • Discoloured teeth - blue/grey or yellow/brown
  • Translucent
  • Teeth are weaker
  • Bulbous crowns
  • Obliteration of pulp chambers
  • Reduced root length
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9
Q

List 2 conditions present at birth cthat can cause a physical disability:

A
  1. Spinal Bifida - neural tube defect
  2. Cerebral palsy - general term for several neurological conditions
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10
Q

What physical affects can Spinal Bifida have on the patient?

A
  • Weakness or total paralysis of the legs
  • Bowel and urinary incontinence
  • Loss of skin sensation
  • Hydrocephalus
  • In most cases normal intelligence but learning difficulties associated with hydrocephalus
  • Repeated fits or seizures
  • Drooling problems and dysphasia
  • Communication and learning difficulties
  • Not progressive, life expectancy not affected
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11
Q

What physical affects can Cerebral palsy have on the patient?

A

Affects movement and coordination:
- Muscle stiffness or floppiness
- Muscle weakness
- Random and uncontrolled body movements
- Balance and coordination problems

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12
Q

List 3 serious illnesses that affect the brain, nerves or muscles:

A
  1. Motor neurone disease
  2. Multiple sclerosis
  3. Parkinson’s disease
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13
Q

What physical affects can Motor Neurone Disease have on the patient?

A

Lethal degenerative disease affecting neurons - can cause:

  • Muscular atrophy, weakness & spasticity
  • No sensory loss
  • Dysphasia and drooling can occur, affecting speech
  • Death within 5 years due to respiratory arrest
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14
Q

What physical affects can Multiple Sclerosis have on the patient?

A

Chronic relapsing CNS disease affecting the corticospinal tract and myelin sheaths:

  • Optic Neuritis can lead to blindness or visual disturbance
  • Weakness or paralysis of limbs
  • Nystagmus (jerky, oscillating movement of the eyes)
  • Ataxia (affects coordination, balance, speech)
  • Dysphasia
  • Loss of sphincter control leading to urinary incontinence
  • May present as V neuralgia or facial palsy
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15
Q

What physical affects can Parkinsons disease have on the patient?

A

Progressive neurological disease causing:

  • Dopamine deficiency
  • Tremor in arms/hands - pill rolling
  • Rigidity in movement
  • Slow movements and restlessness
  • Expressionless face and stooped posture
  • Hyper-salivation resulting in drooling of saliva
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16
Q

List and describe the 2 different levels of spinal cord injuries:

A
  1. Tetraplegic
    - damage to the spinal cord in the neck
    - affects all four limbs and torso
  2. Paraplegic
    - damage to the mid/lower part of the back
    - affects legs and lower body
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17
Q

List 5 causes of spinal cord injuries:

A
  1. Falls
  2. RTAs
  3. Sports injuries
  4. Trauma
  5. Work-related accidents
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18
Q

List 2 different causes of brain injury:

A
  1. External events:
    - closed head trauma
    - missile penetrating the brain
  2. Internal events:
    - Stroke (CVA - cerebrovascular accident)
    - Tumour
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19
Q

List 8 clinical features of stroke:

A
  1. Face drooped on 1 side
  2. Weakness/numbness in 1 arm
  3. Dysphagia
  4. Aphasia - unable to communicate
  5. Dysarthria - Slurred speech
  6. Sudden loss/blurring of vision
  7. Confusions
  8. Sudden and severe headache
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20
Q

How might a stroke affect a patients dental health?

A
  • Difficulty wearing dentures
  • Difficulty brushing teeth
  • Giving consent
  • Accessing surgery (wheelchair)
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21
Q

What acronym can be used when identifying a stroke?

A

F - face drooping
A - arms weakness
S - speech difficulty
T - time to call 999

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22
Q

What outcomes from accidents (e.g. RTAs, falls, sports injuries) can affect a patient’s physical ability?

A
  • Missing limbs
  • Prosthetic limbs
  • Reduced manual dexterity
  • Stick/zimmer
  • Wheelchair
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23
Q

What IQ number classifies someone as having a learning disability?

A

<70

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24
Q

List 6 other features that might be associated with a learning disability:

A
  1. Epilepsy
  2. Visual defects
  3. Hearing and speech disorders
  4. Facial deformities
  5. Body rocking and self-mutilation
  6. Feeding difficulties
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25
List 3 causes of learning disabilities:
1. Genetic 2. Problems during pregnancy/birth 3. Post-natal problems
26
Name 2 different types of learning disabilities:
1. Down Syndrome 2. Fragile X Syndrome
27
Which extra chromosome causes down syndrome?
An extra chromosome 21
28
List 5 physical features of a typical patient with down syndrome:
1. Atlanta-axial joint instability 2. Short stature 3. Brachycephaly 4. Widely spaced upward slanting eyes 5. Weight gain
29
List 8 health conditions that are associated with Down Syndrome:
1. Cardiac problems 2. Spinal problems 3. Malignant disease 4. Dementia 5. Immune disease 6. Hearing loss 7. Visual defects 8. Seizures
30
List 10 oral features associated with down syndrome:
1. Large tongue 2. Thick, dry and fissured lips 3. Poor anterior oral seal 4. Tongue thrust 5. Early onset perio disease - most likely due to poor immune system 6. Cleft lip and palate 7. Malocclusion 8. Delayed tooth eruption 9. Missing teeth 10. Morphological abnormalities
31
What patient management considerations are made when caring for a patient that has Fragile X Syndrome?
The patient may have: - Short attention span - Hyperactivity - Behavioural disorders similar to autism - Abnormally frequent open bite and cross bite
32
What other health conditions might patients with autism have?
- Learning disabilities - ADHD - Dyslexia - Anxiety/depression - Epilepsy - Other conditions - visual/hearing impairment
33
Which health professionals may be involved in the multidisciplinary management of a patient with autism?
- Speech therapist - Paediatrician - Psychiatrist +/-psychologist
34
Describe the typical clinical presentation of a patient with autism:
- Live in their 'own world' - Avoid eye contact - Echolalia - meaningless repetition of words - Unaware of others - Practice repetitive actions - Obsessional desire to follow a routine - Self-mutilation - Sensitivity to touch, smell and sound
35
List 5 oral findings may be apparent in a patient with autism?
1. Bruxism 2. Traumatic 3. Poor OH 4. Poor attender 5. Prefer sweet foods
36
For a patient with autism what must be seen prior to providing patient treatment?
AWI certificate
37
List 5 symptoms of visual impairment:
1. Reduction or loss of vision 2. Eye pain 3. Burning sensation 4. Gritty feeling 5. Blurring of vision
38
List 6 potential causes of visual impairment:
1. Glaucoma 2. Cataract 3. Macular degeneration 4. Diabetic retinopathy 5. Trachoma 6. Hemianopia
39
Which visual fields are affected by Glaucoma?
Peripheral vision (glaucoma - globe (e.g. peripheral))
40
What causes glaucoma?
A rise in intraocular pressure (normal range 15-20mmHg)
41
Is glaucoma often unilateral or bilateral? And is the patients vision likely to recover?
Often bilateral (one eye affected before the other). The patient's vision will never recover.
42
How might a cataract affect vision?
Causes clouding of the lens in the eye. Can cause difficulty with bright lights and seeing at night. (cataract - cloudy)
43
Which visual field is affected by macular degeneration?
Central vision (macular - middle)
44
Which type of macular degeneration is more severe and why?
The wet type is more severe as it causes rapid sight loss of central vision over a matter of months
45
List 7 causes of hearing impairment:
1. Inherited 2. Congenital 3. Infections 4. Trauma 5. Drugs 6. Foreign bodies 7. Excessive noise
46
Which different types of hearing aids are available?
1. Behind the ear aids 2. In the ear aids 3. In the canal aids 4. Hearing implants - bone anchored hearing aids, cochlear implants, auditory brain stem implants, middle ear implants
47
Which legal document exists to support and protect adults (>16yrs) who are: - Unable to safeguard their well-being, property or interests - At risk of harm - More risk because they are affected by a disability, mental disorder, or physical/mental infirmity
The Adult Support and Protection Act 2007
48
In Scotland, what age is a person classified as "an adult"?
16 years old
49
What are the 5 different types of harm?
1. Financial 2. Physical 3. Emotional/Psychological 4. Sexual 5. Neglect
50
At what point should you intervene when you suspect that your patient is undergoing some form of harm?
Intervene only when: 1. The intervention will benefit the adult, which could not reasonably be provided without intervention. 2. The chosen intervention is likely to succeed and is least restrictive of the adult's freedom.
51
Who must you contact if there is any concerns of immediate harm?
999
52
Who can you speak to if you suspect a patient is undergoing non-immediate harm?
1. Line manager, colleague, principle 2. Follow adult protection policy in the practice 3. Defence union/society for advice/support 4. Local Health and Social Care partnership - Adult protection team
53
If there is concern that a proxy may be causing harm the dependant, who may you contact?
Welfare powers - contact social work Financial powers - contact OPG General advice - contact Mental Welfare Commission
54
List the 6 principles of Adult Safeguarding:
1. Empowerment 2. Prevention 3. Proportionality 4. Protection 5. Partnership 6. Accountability
55
Which legal act protects adults in Scotland from any type of harm that occurs within the context of a relationship between partners (married/cohabiting/civil partnership or ex-partners)?
The Domestic Abuse (Scotland) Act 2018
56
What is coercive control? Give examples:
Controlling behaviour is designed to make a person dependent. Examples: - Isolation from support - Exploiting them - Depriving them of independence - Regulating behaviour
57
How can you report domestic abuse?
- Contact 999 if threat to life - Contact 101 if ongoing situation - Report to local police station
58
What can be asked anonymously at the pharmacy to get help when someone is facing domestic abuse?
Ask for ANI (Action Needed Immediately)
59
List 5 different types of exploitation covered in the Human Trafficking and Exploitation Act 2015?
1. Slavery 2. Forced Labour 3. Prostitution 4. Removal of Organs 5. Securing services and benefits
60
What 3 things make consent valid?
It must be: 1. Informed 2. Given freely 3. Given by a capable patient
61
What 5 things may define a patient as incapable?
If the patient is unable to: 1. Act based on information OR 2. Make a decision OR 3. Communicate a decision OR 4. Understand a decision OR 5. Retain memory of a decision (consistency) *in relation to a mental disorder or inability to communicate
62
How might you check that the patient has understood and has the capacity to consent?
"It's my responsibility to check that we are all on the same page and that you understand what you will be expecting at your next appointment, is it okay if you explain it to me in your own words" "Explain it as if they were explaining it to a family member" - ONLY use this technique if they have mentioned a family member "It's important for me to double check"
63
Who does the Adults with Incapacity Act 2000 apply to?
Anyone aged 16 or over who is incapable.
64
What must the patient have before being classified as incapable by certificate?
Must have a diagnosis
65
What are the 5 key principles that should be addressed before issuing a Section 47 Certificate to a patient who lacks capacity to consent to dental treatment?
1. Benefit - must directly benefit the patient. 2. Least restrictive of their freedom. 3. Past and present wishes - the patient's past and present wishes must be taken into account. 4. Consult with relevant others (could be relative, social worker, doctor) 5. Encourage residual capacity
66
What is a proxy?
Someone who has been authorised to act on behalf of an adult with incapacity. - A substitute decision-maker - Legally recognised
67
What are the 3 different types of proxies?
1. Power of Attorney 2. Guardianship 3. Intervener
68
Who can grant a Power of Attorney?
Any adult can grant a power of attorney whilst they have capacity to choose who they wish to act on behalf, should the need arise.
69
What must happen to make a power of attorney official?
1. Must be in writing 2. Must be registered with an OPG (office of the public guardian)
70
Do powers of attorney have an expiry date?
No - however powers of attorney can resign if necessary.
71
What are the 3 different type of power of attorney?
1. Welfare - diet, dress, medical, dental 2. Continuing - house, bills 3. Joint/Combined - welfare + continuing
72
What must you check to confirm that someone is an official authorised proxy?
- Check the original copy/lawyer-endorsed copy of the certificate of registration of power of attorney - must read the bulk of the document and find the text that says: 'The power to consent or withhold consent to medical and dental treatment’ - Can also check with OPG via email
73
What CAN'T a WPoA do?
1. They cannot have more power than a capable patient 2. They cannot authorise the use of force
74
When is a guardianship granted?
When an adult either: 1. No longer has the capacity to choose who they want to make decisions for them. 2. Or has never been able to make their own decisions.
75
How is a guardianship granted?
It is granted by a Sheriff through a court process
76
What is required before granting a guardianship?
2 medical reports and 1 social work report
77
What must a guardianship be registered with?
The guardianship must be registered with an OPG
78
How long does a guardianship normally last?
Usually lasts up to a max of 3 years - however this is up to the Sheriff.
79
If a patient is incapable to make a particular decision and there is a proxy with relevant welfare powers, what should you do?
1. Follow the 5 key principles of the AWI (BLPCE) 2. Get consent from the proxy 3. Have an AWI (Section 47) certificate issued
80
If a patient is incapable to make a particular decision and there is NO proxy with relevant welfare powers, what should you do?
1. Follow the 5 key principles of the AWI 2. Have an AWI (Section 47) certificate issued - this certificate authorises treatment to go ahead
81
What is always required before commencing with treatment, when a patient is deemed incapable, even if there is a proxy?
An AWI certificate
82
An incapable patient attends for emergency treatment without a proxy. You try to contact relatives however unable to get in touch. What should you do?
Treat the patient however be very clear and thorough when documenting your notes. Never leave the patient in pain/refuse to treat them.
83
What is dementia?
The loss of memory, difficulties with language, problem solving, and other thinking abilities that worsens over time.
84
List some risk factors of dementia:
Age Gender - W>M Ethnicity Genetics Down syndrome Medical factors - T2DM, hypertension, high cholesterol, obesity, depression Lifestyle factors - physical inability, smoking, unhealthy diet, excessive alcohol Head injuries
85
What brain condition is linked to repeated knocks to the head during sport and can lead to a specific form of dementia?
Chronic traumatic encephalopathy
86
How can you reduce the risk factors of getting dementia?
Stay mentally and physically active, stop smoking, eat healthily and maintain a healthy weight, reduce alcohol consumption, be social.
87
List the 5 different types of dementia:
1. Alzheimers 2. Vascular 3. Mixed (Alz + Vas) 4. Lewy-Body 5. Fronto-temporal
88
Which type of dementia presents as a slow and steady decline?
Alzheimers
89
How does Alzheimers typically present?
- Short-term memory loss - Word-finding difficulties - Slow and steady decline - More confusion with progression - May experience mood swings and frustration and become more withdrawn.
90
What other infections might Alzheimers be associated with?
Oral herpes, Pneumonia, Spirochete bacteria (syphilis, Lyme disease), and gingivitis.
91
What is the average life expectancy of a patient with Alzheimers?
8-10 years
92
What is the average life expectancy of a patient with Vascular Dementia?
5-10 years
93
What is the cause of vascular dementia?
Reduced blood flow to the brain
94
How does vascular dementia present?
Stepwise pattern decline Often diasoned after a stroke or series of transient ischaemia attacks.
95
How might lewy-body dementia present (3) ?
Unpredictable changes in attention/alertness Disturbed sleep Visual hallucinations
96
How might fronto-temporal dementia present?
Change in personality or behviour Short temperateness pr depreesion
97
Which type of dementia is the most common?
Alzheimers 62%
98
Give an example of a test that can be used to aid diagnosis of dementia?
MMSE - mini-mental state exam
99
What drug treatments are available for dementia?
Doneprezil, Galantasmine, Rivastigmine, Memantine IV infusions that target amyloid to slow the progression of Alzheimer's - e.g. Donanemab is being clinically trialled in the UK
100
List some early signs of dementia:
Changes in ability and behaviour - Often misattributed to stress, bereavement or normal ageing Loss of short-term memory, confusion, poor judgement, unwillingness to make decisions, difficulty making decisions Anxiety, agitation, forgotten appointments, deterioration in OH Forgetting conversations, repeating themselves
101
List some middle phase signs of dementia:
Require more support - eat, wash, dress, go to the toilet Increasingly forgetful Distress, aggression, anger, mood changes Risk of wandering or getting lost May experience hallucinations, patient may not recognise you Repeatedly ask the same question May need domiciliary care
102
For a patient with middle-stage dementia how would you go about treating them in a dental setting?
For dental appointments make sure someone comes with them (partner, carer etc) Find the best time of day for them, may need longer appointments, assess capacity/consent, simple clear words and include them in the conversation
103
Give some examples of signs of late stage dementia:
Increasingly dependent on others Increased physical frailty Difficulty eating/swallowing May acquire pneumonia
104
What are the 2 categories of bleeding disorders?
1. Platelet disorders 2. Clotting disorders
105
List 3 causes of platelet disorders:
1. Failed platelet function 2. Excessive platelet destruction 3. Abnormal platelet function
106
Name a platelet disorder that is described as low platelet production:
Thrombocytopenia
107
What is a normal platelet level?
150-300 x 10^9/L
108
What might cause thrombocytopenia (low platelet production)?
1. Autoimmune disease - e.g. rheumatoid arthritis, lupus etc. 2. Alcoholism 3. Bone marrow diseases 4. Cancer 5. Viruses - e.g. Hep C, HIV 6. Chemotherapy 7. Glanzmanns disease
109
What must you do before carrying out dental treatment on a patient who has a platelet disorder?
1. Liaise with haematology and oncology. 2. Have FBC carried out before the procedure
110
For a patient with a platelet disorder, what must their platelet levels be above before carrying out an extraction?
Platelet levels must be: > 50x10^9/L
111
For a patient with a platelet disorder, what must their platelet levels be above before carrying out major surgery?
Platelet levels must be: > 70x10^9/L
112
What can be used to temporarily aid a patient who has a platelet disorder during dental treatment?
1. Steroids - temporarily increase platelet level 2. Eltrombopag (1x/day for 4 weeks) - temporarily increase platelet level 3. Tranexamic acid - antifibrinolytic, treat/prevent excessive blood loss 4. Platelet transfusion
113
What extra measures can be taken to aid the extraction of a patient with a platelet disorder?
Use LA with a vasoconstrictor (e.g. adrenaline, epinephrine) Pack the socket with a haemostatic agent Suture Apply pressure
114
List 3 different clotting disorders:
1. Von Willebrands Disease 2. Haemophilia A (Factor VIII) 3. Haemophilia B (Factor IX)
115
Which organ is affected when someone has problems with blood clotting?
The liver - as the liver produces clotting factors.
116
What might cause clotting disorders?
1. Liver disease (e.g. liver cancer) 2. Alcoholism - impaired platelet production and interference with clotting factors
117
If a patient has a clotting disorder, what must be done before carrying out and extraction?
1. FBC - full blood count 2. Clotting screen 3. LFTs - liver function test (Liaise with GMP)
118
What is Von Willebrands Factor essential for?
It is an essential for normal platelet adhesion It is also a carrier for factor VIII
119
What is the treatment for VWD?
1. Tranexamic acid 2. Desmopressin - stimulates VWF and increases factor VIII levels - can be given IV, IM, SC, IN 3. Factor VIII - used in severe cases
120
List some symptoms of haemophilia:
- Nose bleeds - Prolonged bleeding from wounds - Bleeding gums - Skin that bruises easily - Pain and stiffness around joints - Internal bleeding
121
List some complications of severe haemophilia:
1. Haematoma - a collection of blood outside of the vessel - can be life threatening 2. Post-extraction bleed - can be life threatening
122
What can a haemophilic patient do to make dental management easier?
They can learn to self-administer their factor VIII concentration before attending dental treatment appointments
123
According to the current WFH Guidelines, when is haemostatic cover therapy required when treating patients with haemophilia?
Needed for: 1. Extractions 2. OS 3. Perio surgery 4. Implant surgery 5. IDBs 6. Lingual infils
124
According to the current WFH Guidelines, when is haemostatic cover therapy NOT required when treating patients with haemophilia?
1. Buccal/palatal infiltration 2. Intraligamental injection 3. Intrapapillary injection
125
When would you refer a patient who has haemophilia to the Dental Hospital for routine dentistry?
You should only refer: 1. In severe cases 2. Presence of inhibitors 3. Rare bleeding disorders *Note - the majority of patients with haemophilia can be safely treated in general practice for routine dentistry.
126
What should you do if your haemophilic patient requires a dental extraction?
DON'T extract the tooth in general practice without liaising with the Haemophilia Centre to organise factor replacement therapy. When factor replacement therapy is provided, use buccal Articaine to reduce the risk of haematoma. Use haemostatic agents: - Tranexamic acid mouthwash (5%) and/or tablets (1g qds) - Topical agents - pressure pack - Sutures - Oxidised cellulose (Surgicel or Gelita- cel) - Fibrin glue
127
What should you do if your haemophilic patient requires: (a) Treatment for gingivitis? (b) Treatment for periodontitis?
(a) Gingivitis - no factor replacement required - TA mouthwash effectively manages post-op bleeding (b) Periodontitis - no factor replacement required (only required in severe cases) - prolonged bleeding can occur, therefore pre and post-op TA mouthwash is recommended
128
What dental challenges may be faced in patients with haemophilia?
- Patient may be reluctant to brush teeth due to fear of bleeding and reluctant to access dental care due to the fear of haemorrhage. - Poorer attendance, higher rates of anxiety, increased rate of extractions, more severe bleeding. - Patients develop inhibitors to replace clotting factors. - Require more expensive drugs
129
List 3 different categories of drugs that affect bleeding:
1. Anti-platelet drugs - aspirin, clopidogrel 2. Anticoagulants - Warfarin, Heparin 3. New Anticoagulants - Dabigatran, Apixaban, Rivaroxaban, Edoxaban
130
If a patient with a bleeding disorder is taking a new oral anticoagulant, what relevant questions should you ask?
1. When do you take them? 2. How many x/day? *It may be appropriate to ask the patient to miss a dose for treatment purposes.
131
List 4 different types of blood cancers:
1. Myeloma 2. Leukaemia 3. Lymphoma 4. Myelodyplasia
132
What is multiple myeloma?
A plasma cell neoplasm that involves the production of abnormal serum immunoglobulins causing infiltration and destruction of bone.
133
What effects can multiple myeloma have on the body?
1. Bone pain - pathological fracture 2. Hyperviscosity syndrome 3. Renal failure 4. Anaemia 5. Neurological lesions
134
How might multiple myeloma affect the patients dental health?
1. Root resorption 2. Loose teeth 3. Mental anaesthesia 4. Pathological fracture 5. Rare cause of mandibular radiolucencies 6. Anaemia 7. Infection 8. Haemorrhagic tendencies 9. Renal failure 10. Patient may be taking steroids, bisphosphonates or other biological therapies
135
What should you do before treating a patient that has multiple myeloma?
Liaise with haematologist.
136
What are the 2 different forms of Leukaemia?
1. Acute 2. Chronic
137
Name 2 types of Acute Leukaemia:
1. Acute lymphoblastic leukaemia 2. Acute myeloid leukaemia
138
Which type of Acute Leukaemia is most common in children?
Acute lymphoblastic Leukaemia
139
Which type of Acute Leukaemia is most common in adults?
Acute myeloid leukaemia
140
Which type of Acute Leukaemia has poorer prognosis?
Acute myeloid leukaemia
141
Name 2 types of Chronic Leukaemia:
1. Chronic lymphocytic leukaemia 2. Chronic myeloid leukaemia
142
How might chronic leukaemia present?
1. Asymptomatic 2. Splenomegaly 3. Lymph node enlargement
143
How might leukaemia affect a person's dental health?
1. Anaemia 2. Bleeding tendencies 3. Susceptible to infections 4. Septicaemia from oral infections - blood poisoning 5. Mucosal pallor 6. Ulceration 7. Gingival swelling 8. Spontaneous bleeding
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What is lymphoma?
Cancer of the lymph glands or other organs of the lymphatic system
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What are the 2 different types of lymphoma?
1. Hodgkins lymphoma 2. Non-Hodgkins lymphoma
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List 5 symptoms of lymphoma:
1. Non-tender swollen lymph nodes 2. Fever 3. Night sweats 4. Unexplained weight loss
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What does Hodgkins lymphoma develop from?
B lymphocytes
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What is Hodgkin's lymphoma characterised by?
Reed-Sternberg cells
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What does Non-Hodgkins Lymphoma affect?
Either B lymphocytes or T lymphocytes
150
Which autoimmune disease puts a patient at an increased risk of developing Non-Hodgkin's Lymphoma?
Sjogrens Syndrome
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How do you treat a low grade lymphoma?
Watch and wait
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How do you treat an aggressive, high-grade lymphoma?
Chemotherapy Radiotherapy Monoclonal antibody therapy (Rituximab)
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What is myelodysplasia?
A rare type of blood cancer where there is not 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 Can develop slowly or quickly
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What can Myelodysplasia develop into?
Acute myeloid leukaemia.
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List some symptoms of Myelodysplasia:
Weakness Tiredness Breathlessness Frequent infections Bruising Easy bleeding - e.g. nosebleeds
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What treatments are available for Myelodysplasia?
1. Injections of growth factor - e.g. Erythropoietin to increase the number of blood cells 2. Blood transfusions 3. Antibiotics 4. Biological therapies - e.g. Lenalidomide 5. Chemotherapy 6. Immunosuppressants 7. Stem cell (bone marrow) transplant
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List some considerations that must be made when treating a patient that has myelodysplasia:
1. They are at an increased risk of bleeding, infection, sepsis, and MRONJ - antibiotics may be necessary. 2. They may be on steroids, undergoing chemotherapy or platelet transfusion 3. Consider appropriate timing for extractions.
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What is MRONJ?
Medication-Related Osteonecrosis of the Jaw - Exposed bone in the maxilla or mandible that has persisted for more than 8 weeks in patients taking anti-resorptive or anti-angiogenic drugs (bisphosphonates, RANKL inhibitors, anti-angiogenic drugs) and where there is no history of radiation or no metastatic disease to the jaws.
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What are the symptoms of MRONJ?
1. Delayed healing after extraction or other trauma: - sometimes spontaneous without an obvious trauma 2. Pain 3. Soft tissue infection and swelling 4. Numbness 5. Exposed bone: - sometimes absent
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What are bisphosphonates and what are they used for?
Drugs that reduce bone resorption by hindering the formation, recruitment and function of osteoclasts. Most commonly used for Osteoporosis to reduce/delay the onset of disease and complications such as bone fractures and pain. However, can also be used in the management of other malignant and non-malignant conditions.
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Alendronate is a type of bisphosphonate. What is the half-life of alendronate?
~10 years
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What are RANKL Inhibitors?
Anti-resorptive drugs that work by inhibiting osteoclast function and bone resorption. Used in bone osteoporosis and cancer.
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Given an example of a RANKL Inhibitor:
Denosumab
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How often is denosumab given to a patient with osteoporosis?
Every 6 months
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How often is denosumab given to a patient with cancer?
Every month
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How long does it take for the effects to diminish following completion of denosumab treatment?
9 months
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What are antiangiogenic drugs used for and what is their action?
Used for the treatment of cancer. They work by restricting the growth of tumour blood vessels.
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Give 3 examples of antiangiogenic drugs:
Lenalidomide Aflibercept Sunitinib
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What are the 4 main renal functions?
1. Excretion of waste products 2. Maintaining fluid/electrolyte balance 3. Secretion of hormones (renin, erythropoietin active vitamin D) 4. Excretion of drugs
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What are the most common causes of chronic kidney disease?
1. Diabetes 2. Hypertension 3. Glomerulonephritis
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What clinical tests can be carried out to assess kidney function and kidney damage?
Blood test - to assess kidney function Urine test - to assess kidney dmage
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List the clinical presentation of renal failure:
Depression Lethargy and Fatigue Nausea and Vomiting Anorexia Weakness Peptic Ulceration Bruising Diarrhoea Bone pain
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List some oral findings related to Chronic Kidney Failure:
Osseous lesions Dry mouth Metallic taste Halitosis Reduced salivary flow Protein and electrolyte changes Accelerated calculus production Pale oral mucosa Oedema Oral ulceration Paraesthesia
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How do you treat Stage 5 Chronic Kidney Disease (End-stage renal disease)?
Either by renal dialysis or kidney transplant.
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What are the 2 different types of renal dialysis?
1. Haemodialysis - performed in health centres/hospitals 3x/week - takes 4 hours 2. Peritoneal dialysis - performed at home by pt or carer - dialysis fluid is exchanged at regular intervals
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What are the issues with renal dialysis when providing dental treatment?
1. The patient will be at an increased risk of bleeding and infection. 2. Must consider drug interactions 3. Must carry out FBC and coagulation screen before carrying out an extraction. 4. Avoid aspirin and other NSAIDs
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When is the best time to carry out dental treatment in a patient who is undergoing haemodialysis?
The best time to carry out treatment is the DAY AFTER HAEMODIALYSIS
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Who can you contact for advice if your patient is having renal dialysis?
Contact their renal physician.
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What are the general complications of having a renal transplant?
1. Lifelong immunosuppression 2. Gingival hyperplasia 3. Increased risk of oral tumours 4. Candidiasis 5. Herpes simplex
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What should you aim to do in terms of dental treatment pre-renal transplant?
1. Full dental assessment 2. Extract teeth of poor prognosis 3. Cons and scaling 4. Preventative regime 5. Make them dentally fit
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What should you aim to do in terms of dental treatment post-renal transplant?
1. Defer elective dental treatment for 6 months 2. Consult with renal physician 3. Expect delayed wound healing
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What are the general side effects of radiotherapy?
Fatigue Nausea Burns Pain
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List 7 oral side effects of radiotherapy:
1. Mucositis 2. Xerostomia 3. Radiation caries 4. Perio disease 5. Dysgeusia/augeusia - loss of taste sensations temp or perm 6. Trismus 7. Osteoradionecrosis
184
How should you manage your dental patient pre-radiotherapy treatment?
1. Prevent ORN from occurring - provide dental screening pre-radiotherapy 2. Extract teeth of poor prognosis as early as pos. - gross caries - mobile teeth (grade 2 or >) - pockets > or = 5mm - PAP - furcation involvement 3. Duraphat toothpaste, varnish and mouthwash 4. Fluoride trays - fill with duraphat toothpaste or mousse, minimum 5 min daily wear 5. Hygiene phase therapy - before and after radiotherapy
185
What adjuncts may aid the patients dental experience post-radiotherapy treatment?
1. Therabite: - If trismus is apparent following radiotherapy, then Therabite may be useful to increase mouth opening during dental treatment. 2. Drugs - Pentoxifylline and Vitamin E can be used for the prevention and management of ORN 3. Hyperbaric oxygen: - To increase oxygen to the damaged bone to promote healing - Limited evidence, not widely available, costly 4. Low-level laser therapy - Currently undergoing trials but promising results
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What are the 3 different types of Chemotherapy?
1. Neoadjuvant/Induction Chemotherapy 2. Adjuvant Chemotherapy +/- Radiotherapy 3. Palliative Chemotherapy
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How does Chemotherapy work?
It works by using drugs to kill rapidly dividing cells It interferes with: - Mitosis - Apoptosis - Tumour cell DNA
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List 3 different types of Chemotherapy drug:
1. Cisplatin 2. Cetuximab 3. TPF
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List some general side effects of Chemotherapy:
1. Fatigue 2. Nausea 3. Vomiting and Diarrhoea 4. Skin rash 5. Hair loss 6. Thrombocytopenia - low platelet levels in blood 7. Neutropenia - low neutrophil levels
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List some oral side effects of Chemotherapy:
Mucositis Infection Bleeding Temporary Xerostomia
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How should you manage your dental patient pre-chemotherapy treatment?
1. Must carry out initial dental screening before chemo 2. Extract hopeless teeth as early as possible before treatment 3. Prevention and hygiene phase therapy
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How should you manage your dental patient post-chemotherapy treatment?
1. For mucositis: - Soft splints - Caphosol - Low-level laser therapy 2. For infection: - Recognise it (fungal, bacterial, viral) - Swab it - Take an oral rinse - Prescribe appropriately 3. For bleeding: - Be prepared for it 4. Check bloods (FBC, coagulation screen) if invasive dental treatment (e.g. extractions) is needed during or soon after chemotherapy. 5. Consider best timing to carry out procedures.
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Before treating a patient who has a cardiac condition, what must you consider?
1. Is their condition stable or unstable? 2. Do they have any other co-morbidities? 3. Is the patient functionally capable? 4. Is the patient anxious? 5. Is the procedure complex?
194
List 5 different cardiac conditions:
1. Congenital 2. Ischaemia 3. Hypertension 4. Cardiomyopathy 5. Transplants
195
What are the 2 different types of congenital heart defect?
1. Cyanotic - e.g. Tetralogy of Fallot 2. Acyanotic - e.g. Ventricular septal defect
196
List some oral findings that may be found in a patient with a congenital heart defect?
1. Delayed eruption of both dentitions 2. Increased positional abnormalities 3. Enamel hypoplasia 4. Vasodilation of pulp 5. Increased periodontal disease 6. Increased caries
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As a dentist, what considerations should you make when treating a patient that has a congenital heart defect?
1. Are they anticoagulated? - May bleed more - Warfarin - must check the patient's INR before carrying out invasive procedures - Follow SDCEP guidance 2. Are they at risk of IE? - Risk assess - Antibiotic prophylaxis against IE is not recommended routinely for patients undergoing dental tx - If unsure use SDCEP guidance or get advice 3. Are there any other associated issues? - e.g. cleft palate
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When should you avoid adrenaline-containing LA in patients that have a cardiac condition?
When the patient has severe hypertension or unstable cardiac rhythm.
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What is ischaemic heart disease?
A result of progressive myocardial ischaemia due to persistently reduced coronary blood flow.
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What might cause ischaemic heart disease?
Atherosclerosis and hypertension, linked to: - smoking - lack of exercise - obesity
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Name the different types of ischaemic heart disease:
1. Angina (stable/unstable) and/or 2. Myocardial Infarction
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What oral findings may be apparent in a patient with IHD?
1. More severe caries and perio disease 2. Angina can RARELY cause of pain in the mandible 3. Drugs used to manage may cause adverse effects: - Lichenoid reactions - Gingival swelling - Angiodema - Ulcers
203
As a dentist, what considerations must be made when treating a patient with IHD?
1. Ask abt frequency of attacks: - When was the last one? - What happened? - Precipitating factors 2. Stable or unstable: - Unstable angina pts should be treated in acute hospital setting 3. Dental treatment may precipitate an angina attack 4. Keep appointments short and stress-free 5. Monitor BP and SpO2 6. Pre-op GTN may be necessary 7. Sedation may be necessary 8. Know how to manage angina/MI in an emergency 9. Be aware that patients may be taking anticoagulants 10. Be aware that patients may be taking beta blockers: - Beta-blockers can increase the toxicity of adrenaline - Use LA that doesn't contain adrenaline 11. DEFER TREATMENT FOR 6 MONTHS POST MI
204
What consistent blood pressure level would indicate that a patient has hypertension?
> 140/90 mmHg
205
What is a normal blood pressure level?
90/60mmHg - 120/80mmHg
206
What are the main causes of hypertension?
1. Unknown (primary) 2. Renal disease (secondary) 3. Endocrine conditions (secondary)
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As a dentist, what must you consider when treating a patient who has hypertension?
1. Hypertension meds can impact oral health: - xerostomia - salivary gland pain/swelling - lichenoid reactions - angio-oedema - gingival hyperplasia - sore mouth - paraesthesia 2. If controlled - it is okay to treat - controlled = <140/90 - severe hypertension = 180/120 3. Important to avoid anxiety and pain 4. Select LA carefully - avoid adrenaline-containing LA if the patient is taking beta blockers 5. Arrange shorter appointments 6. Avoid orthostatic hypertension 7. Consider pre-medication and/or conscious sedation 8. If hypertension is uncontrolled refer to GMP and defer dental treatment until controlled.
208
What is cardiomyopathy?
A group of cardiac conditions that affect the structure of the heart muscle and its ability to pump blood around the body.
209
What causes cardiomyopathy?
1. Genetic 2. Viral infections 3. Autoimmune 4. Medications
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How is cardiomyopathy treated?
1. Medications - Anticoagulants - Beta-blockers - Diuretics 2. Pacemakers or ICDs 3. Surgery 4. Transplant
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As a dentist, what must you consider when treating a patient that has cardiomyopathy?
1. Medications: - Anticoagulants (SDCEP) - Beta-blockers (avoid adrenaline-containing LA) 2. Risk of IE? - Take advice and be aware of guidance 3. Be aware of interference from diathermy, US scalers, EPTs with pacemakers
212
What is heart failure?
When the heart muscle is too weak or too stiff, so unable to pump blood effectively around the body Can be acute or chronic but is usually chronic. Mainly seen in older patients
213
What are the symptoms of heart failure?
Breathlessness Fatigue Swollen ankles
214
What causes heart failure?
1. Hypertension 2. Ischaemic cardiac disease 3. Congenital defects
215
As a dentist, what must you do for your patient pre-cardiac surgery?
1. Must carry out a dental assessment 2. Extract teeth of poor prognosis - severe perio disease - gross caries - apical pathology 3. Fill out examination form if prior to cardiac valve replacement surgery
216
As a dentist, what must you do for your patient pre-transplant surgery?
1. Dental assessment 2. As they are going to be immunosuppressed (lifelong) following surgery you must - extract grossly carious teeth - extract severely periodontally involved teeth - extract any teeth with PAP - follow local protocol if there is one.
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As a dentist, what must you do for your patient post-transplant surgery?
1. Prevention is key 2. Be aware that the patient will be at risk of developing other major conditions/malignancies 3. Anti-rejection drugs will likely have side effects 4. Only carry out invasive treatment 2 years post-transplant after liaising with medical team. - They may be anticoagulated, and/or on steroids - They are at higher risk of infection - They have an impaired drug metabolism 5. Be careful when prescribing - drugs can have interactions.
218
What form is used to assess dental anxiety?
MDAS form
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What should a treatment plan for an anxious patient include?
1. Assessment - assess their anxiety levels, motivation levels - MDAS 2. Psychoeducation - understand their concerns - listen and communicate to the patient that anxiety is normal and that there is treatments/management methods out there to help 3. Rationale for treatment: - use leaflets 4. Coping strategies: - deep breathing - progressive muscular relaxation - grounding 5. Exposure - flooding - face fear straight on - graded - break down into smaller steps 6. End of session - prepare for future difficulties - relapse may occur - encourage practice
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If your patient is needle phobic what must you ask them?
Ask if they have ever fainted during an injection before or at the sight of a needle.
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If the needle-phobic patient has fainted during an injection or at the sight of a needle before and they require another injection, what should you do?
Apply the tension method: - Get them to tense their muscles in their arms, legs and torso for 10-15 seconds. - This helps to prevent a drop in blood pressure.
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If the needle-phobic patient has never fainted during an injection or at the sight of a needle before and they require another injection, what should you do?
Try not to panic them about the possibility of fainting - watch their demeanour and be ready to give instructions of applied tension and make sure if they do faint they can do so safely.
223
What coping mechanism is likely to be the most useful when treating a patient that has experienced previous trauma?
Grounding
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Module 7 (14 decks)

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