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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
Q

List 3 causes of learning disabilities:

A
  1. Genetic
  2. Problems during pregnancy/birth
  3. Post-natal problems
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26
Q

Name 2 different types of learning disabilities:

A
  1. Down Syndrome
  2. Fragile X Syndrome
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27
Q

Which extra chromosome causes down syndrome?

A

An extra chromosome 21

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28
Q

List 5 physical features of a typical patient with down syndrome:

A
  1. Atlanta-axial joint instability
  2. Short stature
  3. Brachycephaly
  4. Widely spaced upward slanting eyes
  5. Weight gain
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29
Q

List 8 health conditions that are associated with Down Syndrome:

A
  1. Cardiac problems
  2. Spinal problems
  3. Malignant disease
  4. Dementia
  5. Immune disease
  6. Hearing loss
  7. Visual defects
  8. Seizures
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30
Q

List 10 oral features associated with down syndrome:

A
  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
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31
Q

What patient management considerations are made when caring for a patient that has Fragile X Syndrome?

A

The patient may have:
- Short attention span
- Hyperactivity
- Behavioural disorders similar to autism
- Abnormally frequent open bite and cross bite

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32
Q

What other health conditions might patients with autism have?

A
  • Learning disabilities
  • ADHD
  • Dyslexia
  • Anxiety/depression
  • Epilepsy
  • Other conditions - visual/hearing impairment
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33
Q

Which health professionals may be involved in the multidisciplinary management of a patient with autism?

A
  • Speech therapist
  • Paediatrician
  • Psychiatrist +/-psychologist
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34
Q

Describe the typical clinical presentation of a patient with autism:

A
  • 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
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35
Q

List 5 oral findings may be apparent in a patient with autism?

A
  1. Bruxism
  2. Traumatic
  3. Poor OH
  4. Poor attender
  5. Prefer sweet foods
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36
Q

For a patient with autism what must be seen prior to providing patient treatment?

A

AWI certificate

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37
Q

List 5 symptoms of visual impairment:

A
  1. Reduction or loss of vision
  2. Eye pain
  3. Burning sensation
  4. Gritty feeling
  5. Blurring of vision
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38
Q

List 6 potential causes of visual impairment:

A
  1. Glaucoma
  2. Cataract
  3. Macular degeneration
  4. Diabetic retinopathy
  5. Trachoma
  6. Hemianopia
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39
Q

Which visual fields are affected by Glaucoma?

A

Peripheral vision

(glaucoma - globe (e.g. peripheral))

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40
Q

What causes glaucoma?

A

A rise in intraocular pressure
(normal range 15-20mmHg)

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41
Q

Is glaucoma often unilateral or bilateral?
And is the patients vision likely to recover?

A

Often bilateral (one eye affected before the other).

The patient’s vision will never recover.

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42
Q

How might a cataract affect vision?

A

Causes clouding of the lens in the eye.

Can cause difficulty with bright lights and seeing at night.

(cataract - cloudy)

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43
Q

Which visual field is affected by macular degeneration?

A

Central vision

(macular - middle)

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44
Q

Which type of macular degeneration is more severe and why?

A

The wet type is more severe as it causes rapid sight loss of central vision over a matter of months

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45
Q

List 7 causes of hearing impairment:

A
  1. Inherited
  2. Congenital
  3. Infections
  4. Trauma
  5. Drugs
  6. Foreign bodies
  7. Excessive noise
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46
Q

Which different types of hearing aids are available?

A
  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
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47
Q

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
A

The Adult Support and Protection Act 2007

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48
Q

In Scotland, what age is a person classified as “an adult”?

A

16 years old

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49
Q

What are the 5 different types of harm?

A
  1. Financial
  2. Physical
  3. Emotional/Psychological
  4. Sexual
  5. Neglect
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50
Q

At what point should you intervene when you suspect that your patient is undergoing some form of harm?

A

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.
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51
Q

Who must you contact if there is any concerns of immediate harm?

A

999

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52
Q

Who can you speak to if you suspect a patient is undergoing non-immediate harm?

A
  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
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53
Q

If there is concern that a proxy may be causing harm the dependant, who may you contact?

A

Welfare powers - contact social work
Financial powers - contact OPG

General advice - contact Mental Welfare Commission

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54
Q

List the 6 principles of Adult Safeguarding:

A
  1. Empowerment
  2. Prevention
  3. Proportionality
  4. Protection
  5. Partnership
  6. Accountability
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55
Q

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)?

A

The Domestic Abuse (Scotland) Act 2018

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56
Q

What is coercive control? Give examples:

A

Controlling behaviour is designed to make a person dependent.

Examples:
- Isolation from support
- Exploiting them
- Depriving them of independence
- Regulating behaviour

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57
Q

How can you report domestic abuse?

A
  • Contact 999 if threat to life
  • Contact 101 if ongoing situation
  • Report to local police station
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58
Q

What can be asked anonymously at the pharmacy to get help when someone is facing domestic abuse?

A

Ask for ANI (Action Needed Immediately)

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59
Q

List 5 different types of exploitation covered in the Human Trafficking and Exploitation Act 2015?

A
  1. Slavery
  2. Forced Labour
  3. Prostitution
  4. Removal of Organs
  5. Securing services and benefits
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60
Q

What 3 things make consent valid?

A

It must be:
1. Informed
2. Given freely
3. Given by a capable patient

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61
Q

What 5 things may define a patient as incapable?

A

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

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62
Q

How might you check that the patient has understood and has the capacity to consent?

A

“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”

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63
Q

Who does the Adults with Incapacity Act 2000 apply to?

A

Anyone aged 16 or over who is incapable.

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64
Q

What must the patient have before being classified as incapable by certificate?

A

Must have a diagnosis

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65
Q

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?

A
  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
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66
Q

What is a proxy?

A

Someone who has been authorised to act on behalf of an adult with incapacity.

  • A substitute decision-maker
  • Legally recognised
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67
Q

What are the 3 different types of proxies?

A
  1. Power of Attorney
  2. Guardianship
  3. Intervener
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68
Q

Who can grant a Power of Attorney?

A

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.

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69
Q

What must happen to make a power of attorney official?

A
  1. Must be in writing
  2. Must be registered with an OPG (office of the public guardian)
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70
Q

Do powers of attorney have an expiry date?

A

No - however powers of attorney can resign if necessary.

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71
Q

What are the 3 different type of power of attorney?

A
  1. Welfare - diet, dress, medical, dental
  2. Continuing - house, bills
  3. Joint/Combined - welfare + continuing
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72
Q

What must you check to confirm that someone is an official authorised proxy?

A
  • 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
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73
Q

What CAN’T a WPoA do?

A
  1. They cannot have more power than a capable patient
  2. They cannot authorise the use of force
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74
Q

When is a guardianship granted?

A

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.
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75
Q

How is a guardianship granted?

A

It is granted by a Sheriff through a court process

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76
Q

What is required before granting a guardianship?

A

2 medical reports and 1 social work report

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77
Q

What must a guardianship be registered with?

A

The guardianship must be registered with an OPG

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78
Q

How long does a guardianship normally last?

A

Usually lasts up to a max of 3 years - however this is up to the Sheriff.

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79
Q

If a patient is incapable to make a particular decision and there is a proxy with relevant welfare powers, what should you do?

A
  1. Follow the 5 key principles of the AWI (BLPCE)
  2. Get consent from the proxy
  3. Have an AWI (Section 47) certificate issued
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80
Q

If a patient is incapable to make a particular decision and there is NO proxy with relevant welfare powers, what should you do?

A
  1. Follow the 5 key principles of the AWI
  2. Have an AWI (Section 47) certificate issued - this certificate authorises treatment to go ahead
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81
Q

What is always required before commencing with treatment, when a patient is deemed incapable, even if there is a proxy?

A

An AWI certificate

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82
Q

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?

A

Treat the patient however be very clear and thorough when documenting your notes.

Never leave the patient in pain/refuse to treat them.

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83
Q

What is dementia?

A

The loss of memory, difficulties with language, problem solving, and other thinking abilities that worsens over time.

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84
Q

List some risk factors of dementia:

A

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

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85
Q

What brain condition is linked to repeated knocks to the head during sport and can lead to a specific form of dementia?

A

Chronic traumatic encephalopathy

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86
Q

How can you reduce the risk factors of getting dementia?

A

Stay mentally and physically active, stop smoking, eat healthily and maintain a healthy weight, reduce alcohol consumption, be social.

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87
Q

List the 5 different types of dementia:

A
  1. Alzheimers
  2. Vascular
  3. Mixed (Alz + Vas)
  4. Lewy-Body
  5. Fronto-temporal
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88
Q

Which type of dementia presents as a slow and steady decline?

A

Alzheimers

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89
Q

How does Alzheimers typically present?

A
  • 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.
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90
Q

What other infections might Alzheimers be associated with?

A

Oral herpes, Pneumonia, Spirochete bacteria (syphilis, Lyme disease), and gingivitis.

91
Q

What is the average life expectancy of a patient with Alzheimers?

A

8-10 years

92
Q

What is the average life expectancy of a patient with Vascular Dementia?

A

5-10 years

93
Q

What is the cause of vascular dementia?

A

Reduced blood flow to the brain

94
Q

How does vascular dementia present?

A

Stepwise pattern decline
Often diasoned after a stroke or series of transient ischaemia attacks.

95
Q

How might lewy-body dementia present (3) ?

A

Unpredictable changes in attention/alertness

Disturbed sleep

Visual hallucinations

96
Q

How might fronto-temporal dementia present?

A

Change in personality or behviour

Short temperateness pr depreesion

97
Q

Which type of dementia is the most common?

A

Alzheimers 62%

98
Q

Give an example of a test that can be used to aid diagnosis of dementia?

A

MMSE - mini-mental state exam

99
Q

What drug treatments are available for dementia?

A

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
Q

List some early signs of dementia:

A

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
Q

List some middle phase signs of dementia:

A

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
Q

For a patient with middle-stage dementia how would you go about treating them in a dental setting?

A

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
Q

Give some examples of signs of late stage dementia:

A

Increasingly dependent on others

Increased physical frailty

Difficulty eating/swallowing

May acquire pneumonia

104
Q

What are the 2 categories of bleeding disorders?

A
  1. Platelet disorders
  2. Clotting disorders
105
Q

List 3 causes of platelet disorders:

A
  1. Failed platelet function
  2. Excessive platelet destruction
  3. Abnormal platelet function
106
Q

Name a platelet disorder that is described as low platelet production:

A

Thrombocytopenia

107
Q

What is a normal platelet level?

A

150-300 x 10^9/L

108
Q

What might cause thrombocytopenia (low platelet production)?

A
  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
Q

What must you do before carrying out dental treatment on a patient who has a platelet disorder?

A
  1. Liaise with haematology and oncology.
  2. Have FBC carried out before the procedure
110
Q

For a patient with a platelet disorder, what must their platelet levels be above before carrying out an extraction?

A

Platelet levels must be:
> 50x10^9/L

111
Q

For a patient with a platelet disorder, what must their platelet levels be above before carrying out major surgery?

A

Platelet levels must be:
> 70x10^9/L

112
Q

What can be used to temporarily aid a patient who has a platelet disorder during dental treatment?

A
  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
Q

What extra measures can be taken to aid the extraction of a patient with a platelet disorder?

A

Use LA with a vasoconstrictor (e.g. adrenaline, epinephrine)

Pack the socket with a haemostatic agent

Suture

Apply pressure

114
Q

List 3 different clotting disorders:

A
  1. Von Willebrands Disease
  2. Haemophilia A (Factor VIII)
  3. Haemophilia B (Factor IX)
115
Q

Which organ is affected when someone has problems with blood clotting?

A

The liver - as the liver produces clotting factors.

116
Q

What might cause clotting disorders?

A
  1. Liver disease (e.g. liver cancer)
  2. Alcoholism - impaired platelet production and interference with clotting factors
117
Q

If a patient has a clotting disorder, what must be done before carrying out and extraction?

A
  1. FBC - full blood count
  2. Clotting screen
  3. LFTs - liver function test

(Liaise with GMP)

118
Q

What is Von Willebrands Factor essential for?

A

It is an essential for normal platelet adhesion

It is also a carrier for factor VIII

119
Q

What is the treatment for VWD?

A
  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
Q

List some symptoms of haemophilia:

A
  • Nose bleeds
  • Prolonged bleeding from wounds
  • Bleeding gums
  • Skin that bruises easily
  • Pain and stiffness around joints
  • Internal bleeding
121
Q

List some complications of severe haemophilia:

A
  1. Haematoma
    - a collection of blood outside of the vessel
    - can be life threatening
  2. Post-extraction bleed
    - can be life threatening
122
Q

What can a haemophilic patient do to make dental management easier?

A

They can learn to self-administer their factor VIII concentration before attending dental treatment appointments

123
Q

According to the current WFH Guidelines, when is haemostatic cover therapy required when treating patients with haemophilia?

A

Needed for:

  1. Extractions
  2. OS
  3. Perio surgery
  4. Implant surgery
  5. IDBs
  6. Lingual infils
124
Q

According to the current WFH Guidelines, when is haemostatic cover therapy NOT required when treating patients with haemophilia?

A
  1. Buccal/palatal infiltration
  2. Intraligamental injection
  3. Intrapapillary injection
125
Q

When would you refer a patient who has haemophilia to the Dental Hospital for routine dentistry?

A

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
Q

What should you do if your haemophilic patient requires a dental extraction?

A

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
Q

What should you do if your haemophilic patient requires:

(a) Treatment for gingivitis?
(b) Treatment for periodontitis?

A

(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
Q

What dental challenges may be faced in patients with haemophilia?

A
  • 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
Q

List 3 different categories of drugs that affect bleeding:

A
  1. Anti-platelet drugs - aspirin, clopidogrel
  2. Anticoagulants - Warfarin, Heparin
  3. New Anticoagulants - Dabigatran, Apixaban, Rivaroxaban, Edoxaban
130
Q

If a patient with a bleeding disorder is taking a new oral anticoagulant, what relevant questions should you ask?

A
  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
Q

List 4 different types of blood cancers:

A
  1. Myeloma
  2. Leukaemia
  3. Lymphoma
  4. Myelodyplasia
132
Q

What is multiple myeloma?

A

A plasma cell neoplasm that involves the production of abnormal serum immunoglobulins causing infiltration and destruction of bone.

133
Q

What effects can multiple myeloma have on the body?

A
  1. Bone pain - pathological fracture
  2. Hyperviscosity syndrome
  3. Renal failure
  4. Anaemia
  5. Neurological lesions
134
Q

How might multiple myeloma affect the patients dental health?

A
  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
Q

What should you do before treating a patient that has multiple myeloma?

A

Liaise with haematologist.

136
Q

What are the 2 different forms of Leukaemia?

A
  1. Acute
  2. Chronic
137
Q

Name 2 types of Acute Leukaemia:

A
  1. Acute lymphoblastic leukaemia
  2. Acute myeloid leukaemia
138
Q

Which type of Acute Leukaemia is most common in children?

A

Acute lymphoblastic Leukaemia

139
Q

Which type of Acute Leukaemia is most common in adults?

A

Acute myeloid leukaemia

140
Q

Which type of Acute Leukaemia has poorer prognosis?

A

Acute myeloid leukaemia

141
Q

Name 2 types of Chronic Leukaemia:

A
  1. Chronic lymphocytic leukaemia
  2. Chronic myeloid leukaemia
142
Q

How might chronic leukaemia present?

A
  1. Asymptomatic
  2. Splenomegaly
  3. Lymph node enlargement
143
Q

How might leukaemia affect a person’s dental health?

A
  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
144
Q

What is lymphoma?

A

Cancer of the lymph glands or other organs of the lymphatic system

145
Q

What are the 2 different types of lymphoma?

A
  1. Hodgkins lymphoma
  2. Non-Hodgkins lymphoma
146
Q

List 5 symptoms of lymphoma:

A
  1. Non-tender swollen lymph nodes
  2. Fever
  3. Night sweats
  4. Unexplained weight loss
147
Q

What does Hodgkins lymphoma develop from?

A

B lymphocytes

148
Q

What is Hodgkin’s lymphoma characterised by?

A

Reed-Sternberg cells

149
Q

What does Non-Hodgkins Lymphoma affect?

A

Either B lymphocytes or T lymphocytes

150
Q

Which autoimmune disease puts a patient at an increased risk of developing Non-Hodgkin’s Lymphoma?

A

Sjogrens Syndrome

151
Q

How do you treat a low grade lymphoma?

A

Watch and wait

152
Q

How do you treat an aggressive, high-grade lymphoma?

A

Chemotherapy

Radiotherapy

Monoclonal antibody therapy (Rituximab)

153
Q

What is myelodysplasia?

A

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

154
Q

What can Myelodysplasia develop into?

A

Acute myeloid leukaemia.

155
Q

List some symptoms of Myelodysplasia:

A

Weakness
Tiredness
Breathlessness
Frequent infections
Bruising
Easy bleeding - e.g. nosebleeds

156
Q

What treatments are available for Myelodysplasia?

A
  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
157
Q

List some considerations that must be made when treating a patient that has myelodysplasia:

A
  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.
158
Q

What is MRONJ?

A

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.
159
Q

What are the symptoms of MRONJ?

A
  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
160
Q

What are bisphosphonates and what are they used for?

A

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.

161
Q

Alendronate is a type of bisphosphonate.

What is the half-life of alendronate?

A

~10 years

162
Q

What are RANKL Inhibitors?

A

Anti-resorptive drugs that work by inhibiting osteoclast function and bone resorption.

Used in bone osteoporosis and cancer.

163
Q

Given an example of a RANKL Inhibitor:

A

Denosumab

164
Q

How often is denosumab given to a patient with osteoporosis?

A

Every 6 months

165
Q

How often is denosumab given to a patient with cancer?

A

Every month

166
Q

How long does it take for the effects to diminish following completion of denosumab treatment?

A

9 months

167
Q

What are antiangiogenic drugs used for and what is their action?

A

Used for the treatment of cancer.

They work by restricting the growth of tumour blood vessels.

168
Q

Give 3 examples of antiangiogenic drugs:

A

Lenalidomide
Aflibercept
Sunitinib

169
Q

What are the 4 main renal functions?

A
  1. Excretion of waste products
  2. Maintaining fluid/electrolyte balance
  3. Secretion of hormones (renin, erythropoietin active vitamin D)
  4. Excretion of drugs
170
Q

What are the most common causes of chronic kidney disease?

A
  1. Diabetes
  2. Hypertension
  3. Glomerulonephritis
171
Q

What clinical tests can be carried out to assess kidney function and kidney damage?

A

Blood test - to assess kidney function

Urine test - to assess kidney dmage

172
Q

List the clinical presentation of renal failure:

A

Depression
Lethargy and Fatigue
Nausea and Vomiting
Anorexia
Weakness
Peptic Ulceration
Bruising
Diarrhoea
Bone pain

173
Q

List some oral findings related to Chronic Kidney Failure:

A

Osseous lesions
Dry mouth
Metallic taste
Halitosis
Reduced salivary flow
Protein and electrolyte changes
Accelerated calculus production
Pale oral mucosa
Oedema
Oral ulceration
Paraesthesia

174
Q

How do you treat Stage 5 Chronic Kidney Disease (End-stage renal disease)?

A

Either by renal dialysis or kidney transplant.

175
Q

What are the 2 different types of renal dialysis?

A
  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
176
Q

What are the issues with renal dialysis when providing dental treatment?

A
  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
177
Q

When is the best time to carry out dental treatment in a patient who is undergoing haemodialysis?

A

The best time to carry out treatment is the DAY AFTER HAEMODIALYSIS

178
Q

Who can you contact for advice if your patient is having renal dialysis?

A

Contact their renal physician.

179
Q

What are the general complications of having a renal transplant?

A
  1. Lifelong immunosuppression
  2. Gingival hyperplasia
  3. Increased risk of oral tumours
  4. Candidiasis
  5. Herpes simplex
180
Q

What should you aim to do in terms of dental treatment pre-renal transplant?

A
  1. Full dental assessment
  2. Extract teeth of poor prognosis
  3. Cons and scaling
  4. Preventative regime
  5. Make them dentally fit
181
Q

What should you aim to do in terms of dental treatment post-renal transplant?

A
  1. Defer elective dental treatment for 6 months
  2. Consult with renal physician
  3. Expect delayed wound healing
182
Q

What are the general side effects of radiotherapy?

A

Fatigue
Nausea
Burns
Pain

183
Q

List 7 oral side effects of radiotherapy:

A
  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
Q

How should you manage your dental patient pre-radiotherapy treatment?

A
  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
Q

What adjuncts may aid the patients dental experience post-radiotherapy treatment?

A
  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
186
Q

What are the 3 different types of Chemotherapy?

A
  1. Neoadjuvant/Induction Chemotherapy
  2. Adjuvant Chemotherapy +/- Radiotherapy
  3. Palliative Chemotherapy
187
Q

How does Chemotherapy work?

A

It works by using drugs to kill rapidly dividing cells

It interferes with:
- Mitosis
- Apoptosis
- Tumour cell DNA

188
Q

List 3 different types of Chemotherapy drug:

A
  1. Cisplatin
  2. Cetuximab
  3. TPF
189
Q

List some general side effects of Chemotherapy:

A
  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
190
Q

List some oral side effects of Chemotherapy:

A

Mucositis
Infection
Bleeding
Temporary Xerostomia

191
Q

How should you manage your dental patient pre-chemotherapy treatment?

A
  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
192
Q

How should you manage your dental patient post-chemotherapy treatment?

A
  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.
193
Q

Before treating a patient who has a cardiac condition, what must you consider?

A
  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
Q

List 5 different cardiac conditions:

A
  1. Congenital
  2. Ischaemia
  3. Hypertension
  4. Cardiomyopathy
  5. Transplants
195
Q

What are the 2 different types of congenital heart defect?

A
  1. Cyanotic
    - e.g. Tetralogy of Fallot
  2. Acyanotic
    - e.g. Ventricular septal defect
196
Q

List some oral findings that may be found in a patient with a congenital heart defect?

A
  1. Delayed eruption of both dentitions
  2. Increased positional abnormalities
  3. Enamel hypoplasia
  4. Vasodilation of pulp
  5. Increased periodontal disease
  6. Increased caries
197
Q

As a dentist, what considerations should you make when treating a patient that has a congenital heart defect?

A
  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
198
Q

When should you avoid adrenaline-containing LA in patients that have a cardiac condition?

A

When the patient has severe hypertension or unstable cardiac rhythm.

199
Q

What is ischaemic heart disease?

A

A result of progressive myocardial ischaemia due to persistently reduced coronary blood flow.

200
Q

What might cause ischaemic heart disease?

A

Atherosclerosis and hypertension, linked to:
- smoking
- lack of exercise
- obesity

201
Q

Name the different types of ischaemic heart disease:

A
  1. Angina (stable/unstable)

and/or

  1. Myocardial Infarction
202
Q

What oral findings may be apparent in a patient with IHD?

A
  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
Q

As a dentist, what considerations must be made when treating a patient with IHD?

A
  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
Q

What consistent blood pressure level would indicate that a patient has hypertension?

A

> 140/90 mmHg

205
Q

What is a normal blood pressure level?

A

90/60mmHg - 120/80mmHg

206
Q

What are the main causes of hypertension?

A
  1. Unknown (primary)
  2. Renal disease (secondary)
  3. Endocrine conditions (secondary)
207
Q

As a dentist, what must you consider when treating a patient who has hypertension?

A
  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
Q

What is cardiomyopathy?

A

A group of cardiac conditions that affect the structure of the heart muscle and its ability to pump blood around the body.

209
Q

What causes cardiomyopathy?

A
  1. Genetic
  2. Viral infections
  3. Autoimmune
  4. Medications
210
Q

How is cardiomyopathy treated?

A
  1. Medications
    - Anticoagulants
    - Beta-blockers
    - Diuretics
  2. Pacemakers or ICDs
  3. Surgery
  4. Transplant
211
Q

As a dentist, what must you consider when treating a patient that has cardiomyopathy?

A
  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
Q

What is heart failure?

A

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
Q

What are the symptoms of heart failure?

A

Breathlessness
Fatigue
Swollen ankles

214
Q

What causes heart failure?

A
  1. Hypertension
  2. Ischaemic cardiac disease
  3. Congenital defects
215
Q

As a dentist, what must you do for your patient pre-cardiac surgery?

A
  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
Q

As a dentist, what must you do for your patient pre-transplant surgery?

A
  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.
217
Q

As a dentist, what must you do for your patient post-transplant surgery?

A
  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
Q

What form is used to assess dental anxiety?

A

MDAS form

219
Q

What should a treatment plan for an anxious patient include?

A
  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
220
Q

If your patient is needle phobic what must you ask them?

A

Ask if they have ever fainted during an injection before or at the sight of a needle.

221
Q

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?

A

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.
222
Q

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?

A

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
Q

What coping mechanism is likely to be the most useful when treating a patient that has experienced previous trauma?

A

Grounding

224
Q
A

Module 7 (14 decks)

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