Special Care Lectures Flashcards
1
Q
adult support and protection agencies should
A
- refer to their own policies and procedures
- are responsible for providing adult support and protection training
2
Q
adult support and protection committee
A
- in place by law
- has overarching responsibility for governance, quality assurance and multiagency collaborations across the partership
3
Q
Adult support and protection
key legislation
A
- ASP act 2007
- adults with incapacity act 2000
- mental health (care and Treatement) act 2003
- human rights act 1998
4
Q
mental health act 2003 summary
A
enables medical professionals to detain and treat people on the grounds of mental disorder
5
Q
ASP act implementation and reason for introduction
A
- adult support and protection act 2007
- implemented in 2008
- introduced new measures to identify and protect “adults at risk of harm”
- contained new definitions and terminology “abuse” replaced with “harm”
- “vulnerable adult” replaced with “adult at risk”
6
Q
adult at risk
3 point test
A
- to be defined as adult at risk must meet all 3 points called 3 point test
- adults aged 16 and over who
1. are unable to safeguard their own wellbeing, property, rights or other interests
2. are at risk of harm
3. because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulneravle to being harmed than unaffected adults
7
Q
adults are deemed to be “at risk of harm” when
A
- another persons conduct is causing the adult to be harmed
- the adult is engaging in conduct which causes self-harm
8
Q
adult support and protection principles
A
- intervention must benefit the adult
- be the least restrictive option
- have regard to the adults ascertainable wishes
- take account the view of the adults nearest relative, primary carer, POA etc
- encourage participation of the adult and take into account adults abilities, background and characteristics
9
Q
multi-agency bodies set out by adult support and protection act
A
- council
- NHS
- police
- care inspectorate
- more similar public bodies involved
- they must report to council when they believe an adult is at risk
- must co-operate with the council to assist with their inquiries and share info
- consent of the adult not required
10
Q
Adult support and protection capacity and consent considerations
A
- adult can lack capacity and stillbe referred under ASP legislation
- adult does not need to consent to referral being made
- must have evidence if taking action against adults wishes (known as undue pressure)
11
Q
types of harm
A
- sexual harm
- physical harm
- emptional/psychological
- self harm
- verbal
- neglect
- finance
- discriminatory
- multiple forms of harm
12
Q
other types of harm
A
- forced marriage
- honour based violence
- female genital mutilation
- human trafficking
- fire casualty
- online safety
13
Q
ASP duty to inquire
A
- first step in ASP process to establish whether 3 point test is met and risk assessment
- completed by social work staff
- checking background information
- speak to others involved GP carers etc and to the adult at risk of harm
- consent of adult not required
14
Q
ASP protection order types
A
- assessment order - allows adult to be takent to a more suitable place for an interview or medical examination
- removal order - permits adult to be moved to any placed to protect from harm (usually care home)
- banning order - bans subject from a specified place
- warrant for entry - allows council officer access to the adult at risk
15
Q
adult support and protection
how do I report my concerns
A
- the three R’s: recognise, record and report
- immediate danger call 999
- speak to line manager
- refer to agency adult protection procedures
- complete AP1 and send to social care direct
16
Q
oncology
role of GDP
A
- early detection through soft tissue examination
- photographs
- onward referral
- pre-treatment assessment
17
Q
oncology guidance to follow
A
- scottish cancer referral guidelines
- NICE improving outcomes in head and neck cancers
- ENT UK
- there are more not listed
18
Q
indications for head and neck cancer referral
A
- stridor - emergency referral required
- persistent unexplained head nad neck lumps > 3 weeks
- ulceration or unexplained swelling of OM >3 weeks
- red or mixed red and white patches of OM >3weeks
- persistent hoarseness > 3 weeks (chest x ray request also)
- dysphagia or odynophagia > 3 weeks
- persistent throat pain > 3 weeks
19
Q
head and neck cancer
investigation and diagnoses steps
A
- new pt assessment within OMFS
- biopsy to confirm diagnosis
- CT scan to investiate extent of tumour and metastasis
- lymph node biopsy
- stage and grade cancer
20
Q
multidisciplinary team for tx head and neck cancer
A
- ocologist
- radiologist
- surgeon - ENT, OMFS, plastics
- specialist nurse
- dentist
- psychologist
- physio
- OT
21
Q
key timelines for head and neck cancer tx
A
- first appt within 14 days of referral
- specialist investigations and diagnosis within 31 days
- start of definitive tx within 62 days
22
Q
oncology pre tx assessment aims
A
- include full detailed examination and radiographs OPT and peri-apicals
- identify existing disease or risk of disease
- remove infection and potential infection BEFORE cancer therapy
- prepare pt for expected side effect of cancer tx
- establish gd OH and develop plan for maintaining OH
- plan post-tx prosthetic oral rehabilitation
23
Q
oncology pre assessment tx we can provide
A
- detailed OHI and diet advice
- fluoride application, toothpaste etc
- PMPR
- consider chlorhexidine MW and gel (alcohol free)
- restore carious teeth
- removal of trauma - sharp edges
- impressions and construct fluoride trays, soft splints
24
Q
oncology other pre cancer tx dental tx
A
- extract teeth with poor progress no less than 10days before starting cancer tx
- antibiotic prophylaxis if neutrophils low and invasive tx - liase with medics
- remove any ortho tx/appliance
- smoking and alcohol advice
- study casts for implant planning
25
oral cancer tx includes
* surgical resection - with or without reconstruction
* radiotherapy
* chemotherapy
* adjuvant radiotherapy or chemotherapy may be required following surgical resection
26
oral cancer tx side effects
* altered anatomy due to resection - can affect appearance and function
* radiation damage to normal tissues surrounding tumour
* chemotherapy causes acute mucosal and haematological toxicity
* adverse effects on respiration, mastication, swallowing, speech, taste, SG function, mouth opening
27
dentist role during cancer therapy
* avoid dental tx
* hygienist support
* oral and denture hygiene
* antibacterial MW short term alternative to brushing
* diet advice
* fluoride preparations
* examine for fungal/viral infections due to increased risk
* tx/symptomsrelief of mucositis, xerostomia
28
dental issues during cancer tx
oral mucositis
* begins 1-2 weeks after tx starts
* lasts until approx 6 weeks after tx ends
* severe pain from mucositis may inhibit oral hygiene measures
* severe impact on eating - tube fed
29
dental issues during cancer tx
prevention and management of oral mucositis
* caphosol mouth rinse - neutral supersaturated calcium phosphate, soluble aspirin, mucoadhesive oral rinse, aloe vera, difflam spray
* low level laser therapy if radiotherapy tx
* morphine and opioids required as analgesics
* OH
* oral cooling (ice)
* 2% lidocaine mouth wash prior to eating
30
dental issues during cancer tx
candida infections
* common and extremely uncomfortable
* antifungal drugs can prevent although nistatin not effective
* preventative antifungals often prescribed - chlorhexidine mouthwash, miconazole (topical), fluconazole (systemic)
31
dental issues during cancer tx
traumatic ulceration
* often caused by teeth rubbing delicate intraoral tissues
* can give soft splint
32
dental issues during cancer tx
* oral mucositis
* candida infections
* traumatic ulceration
* reactivation of herpes simplex
* xerostomia
* trismus
* dental erosion
* caries
* perio disease
* ORN
33
dental issues during cancer tx
reactivation of herpes simplex virus
* coldsore virus
* prodromal period - pain prior to reulcertion - need systemic antivirals
* sudden onset
* more extensive and aggressive
* high index of clinical suspicion
34
dental issues during cancer tx
xerostomia
* saliva more acidic and viscous
* affects chewing, swallowing, taste
* higher risk of caries, perio, candida, sialadenitis, pros difficulties
* caused by radiation damage to salivary tissue
* oral gel or lubricants eg vaseline to coat and protect lips and soft tissues
* pilocarpine HCl can enhance salivary excretions
* sugar free chewing gum
* frequent sips of water
* avoid acidic saliva replacement
35
dental issues during cancer tx
trismus
* causes - post surgical inflammation, fibrosis of tissues,
* trismus due to radiotheray can occur rapidly over first 9 months after tx - tends to be progressive and may be irreversible
* causes problems with eating, speaking, access for oral self care etc
* tx - physical therapy and devices which stretch MOM (therabite and stacked tongue depressors etc)
36
dental issues during cancer tx
dental erosion
* can be due to:
* low salival pH
* use of glandosane
* drinking acidic drinks due to dry mouth
37
dental issues during cancer tx
caries
* can be due to - xerostomia, difficulty with OH, change indiet, difficulty swallowing
* prevention - OHI, diet advice, fluoride therapy
* radiation induced caried - may affect incisal edges, result of reduced salivary flow
38
dental issues during cancer tx
periodontal disease
* can be affected by depression and poor self care
* importance of regular dental assessment following cancer tx
39
dental issues during cancer tx
osteoradionecrosis ORN
* area of exposed bone in an irradiated side not due to tumour recurrence - least 3 months
* prevention - remove poor prognosis teeth, extractions at least 10 days prior to radiotherapy, encourage healing with primary closure/sutures where possible
* HBOT (hyperbaric oxygen therapy) in a systematic review shown to reduce incidence but no clear evidence
* recommend antibiotic prophylaxis and use until completion of healing - although no conclusive evidence
40
dental issues during cancer tx
ORN risks
* total radiation dose exceeded 60Gy
* large dose fraction and high number of fractions
* local trauma from XLA
* uncontrolled perio
* immunodeficient individual
* consider use of fentoxyfylline and vitamin E
41
staging ORN
* ORN = osteoradionecrosis
* stage 0 = mucosal defects only and bone exposed
* I = dento-alveolar only and radiographic evidence of necrotic bone
* II = radiographic findings above ID canal with denuded bone introrally
* III = clinically exposed radionecrotic bone, skin fistulas, infection
42
ORN prevention and tx
* regular examination <6 monthly
* radiographs
* avoid invasive tx that could traumatise bone (surgical XLA etc) - consider decoronating and leaving roots
* caries management - resin rest, SS crowns
* antimicrobials for acute conditions
43
oral cancer pts
reconstruction and maintenance
* implants - reduced success if irradiated bone, requires maintenance, restorative specialist required
* dentures avoid where possible - hygiene essential as risk of candida infection
* review regularly
44
adults with incapacity act summary
* framework for safeguarding the welfare and managing the finances of adults who lack capacity
* act aims to protect people who lck capacity to make particular decisions, but also support their involvement in making decisions as far as they are able to do so
45
assessment of capacity key points
* presume capacity
* AMCUR
* is decision or action specific
* capacity may fluctuate
* record your assessment
* seek advice when needed
46
incapacity is being incapable of
* AMCUR
* acting
* making a decision
* communicating decision
* understanding decision
* retaining the memory of decision
47
incapacity legal definition
* inability of an adult to enter legally binding contracts
* adult means a person who is age 16 or older
* an adult with a condition, to the extent that they cannot understand what a decision involves or make a true choice
* if a person with incapacity makes a decision it has no legal effect
48
capacity - communication
* persn cannot be considered to lack capacity because they are deficient in communication if it can be made good by human or mechanical aid
* must be supported to maximise their communication
* allow adequate time
* find out how person communicates
* use technology - loop systems, spelling bords, ipad etc
* consider communication adjuncts
49
demonstrating capacity
* understand in simple language what tx is, purpose of tx and why its being proposed
* understand risks and benefits and alternatives
* understand consequences of not recieving tx
* retain the memory of the decision
50
principles of AWI act
1. benefit
2. minimum necessary intervention
3. take account the wishes of the adult
4. consultation with relevant others
5. encourage adult to exercise residual capacity
51
types of proxy
* power of attorney
* continuing POA - cannot consent for dental
* welfare POA - can consent
* combined POA - can consent
* guardianship orders
* welfare guardian - can consent
* financial guardian - cannot consent
52
power of attorney summary
* granted while a pt has capacity
* powers dormant until demonstrated they are needed
* no expiry date
* can be done via lawer - does not need to go to court
* will be registered with the office of public guardian OPG
* can be more than one person
53
types of power of attorney
* continuing POA - only covers financial affairs and property
* welfare POA - welfare decisions including healthcare, dressing, eating, can consent to dental tx
* combines POA - welfare and financial decisions, can consent to dental tx
54
guardianship orders summary
* court appointed preson to make decisions on behalf of AWI
* appointed by sheriff after adult has lost capacity
* welfare or financial guardian - can be both
* usually appointed for three years
55
who can consent for dental tx
* patients with capacity
* welfare power of attorney
* welfare guardians
* medical and dental practitioners under AWI act in emergency situation - limited in dentistry, if tx necessary for preservation of life or to prevent serious deterioration
56
certificates of incapacity
who can issue
* general medical practitioners
* consultant in charge of pts care
* with required training: dental practitioners, registered nurses, optometrists
* even where a proxy has been appointed a certificate of incapacity MUST also be completed
57
GDP role in adult with incapacity
* unlikely to have power to sign certificate of incapacity AWI section 47 form
* unless completed required training
* therefore required to liase with GMP - provide GMP details
58
define a bariatric person
* an individual of any age
* who has limitations in health and social care due to physical size, health, mobility and environmental access
* scottish health survey 2018 65% adults overwight and 28% obese
59
body mass index
WHO definitions and limitations
* WHO defines overweight as BMI >= 25kg/m^2 and obesity as >=30kg/m^2
* defined as wight in kilograms divided by square height in metres
* limitations - does not assess body fat distribution, or account for age, sex, ethnicity and muscle mass
60
obesity contributing factors
* underlying health problems
* fundamental cause is imbalance between calories consumed and calories expended
* lack of energy
* difficulty chewing or swallowing food
* physical limitations to reduce ability to exercise
* lifestyle factors - unhealthy food, lack of exercise environment, resources
61
obesity in equality act 2010
* does not classify obesity as a disability
* failure to provide suitable facilities for bariatric pts has potential to breach equality act 2010
* responsibility of GDP to make reasonable adjustments to aid access
62
bariatric dental care
role of the dental team
* identify and diagnose oral health issues
* signpost pts to appropriate services - weight management, GMP
* be aware of co-morbidities or predisposition to dental disease
63
equiptment in management of bariatric pt
* regular dental chair has safe working limit of 22 stone/140kg
* higher weight dental chair SWL = 32stone
* wheelchair recliner if pt >32 stone SWL= 79 stone
* can also use bariatric wheelchair
* heavy weight hospital hoists can be used to tranfer from pts own bariatric wheelchair to higher weight dental chair
64
medical complications of obesity
* hypertension and CVD
* diabetes
* sleep apnoea
* dyspnoea - breathlessness
* GORD
* osteoarthritis
* liver and gallbladder disease
* mental health disorders
65
bariatric care
dental tx difficulties and adjustments
* loss of anatomical landmarks is possible
* access issues with large cheeks, tongue etc - consider use of tongue retractor
* ID block may be difficult
* may have to be treated semi-supine or sitting upright
* IO radiography more challenging due to increased soft tissues
* long procedures can lead to acute leg oedema, cellulitis, pressure sores
* coagulation abnormalities may occur
66
dental implications of obesity
* association with perio disease but no evidence of causation - diabetic pts increased risk
* increased caries if diet high in processed sugars
* tend to have reduced immune function - delayed wound healing
* erosive toothwear more likely as increased prevalence of GORD - especially in those having gastric banding
67
domiciliary care for bariatric pts
* rarely first option
* useful when pts too large or anxious to leave home
* tx usually limited to inexpensive, short procedures such s examinations
* most common procedure is prosthetics
68
sedation and bariatric care
* inhalation sedation - no specific contraindications but care taken to ensure good safe airway mangement
* IV sedation - obese adults at risk of sleep apnoea which is contraindication in primary setting
* bariatric adults not suitable for conscious sedation in standard dental clinic due to difficulty pacing cannula
* GA - twice as likely to develop serious airway problems during GA
69
bariatric surgery dental problems
* correlation with perio disease, caries, ulcers, dentine sensitivity and halitosis
* higher frequency of meals following surgery = increased risk of caries
* increased risk of dental eorison due to common side effect of reflux and vomiting
70
GDP messages to bariatric surgery pts
* healthy balanced diet important - reduce sugar consumption
* adequate OH
* brush tongue or use tongue scraper to reduce halitosis
* drik juices through straw - never brush right afterwards
* provide topical fluoride varnish and OHI as required
71
older person symposium
tasks people can struggle with
* mobility - stairs, getting to the shops
* dexterity - brushing teeth
* communication - sight and hearing - isolation
72
older person symposium
medical diseases
* musculoskeletal - arthritis, osteoporosis, gout
* diabetes, hormonal dysfunction
* cognitive impairement
* visual and hearing conditions
* CV conditions
* GI
* malignancy
73
what is dementia
* syndrome resulting in the deterioration in cognitive function
* an aquired progressive loss of cognitive functions, intellectual and social abilities
* severe enough to interfere with daily functioning
74
dementia characterised by
* amnesia
* inability to concentrate
* disorientation in time, place or person
* intellectual impairment
75
dementia pts often have problems with
* memory - difficulty recalling recent events
* concentrating, planning, making decisions
* language - following a conversation or finding right words to say
* visuospatial - problems judging distances and seeing objects in 3D
* orientation - losing track of day or date, confused about where they are
76
types of dementia
* alzheimers
* vascular dementia
* dementia with lewy bodies
* frontotemporal
* rarer forms - HIV related, parkinsons, MS
77
describe alzheimers
* most common type of dementia
* reduction in size of the cortex - severe in hippocampus
* plaques build up in spaces between nerve cells
* tangles (twisted protein fibres) build up inside cells
* features - short term memory loss, aphasia, confusuion, mood swings
78
alzheimers associated factors
* age
* women > men
* head injury
* increased risk - smoking, hypertension, low folate, high blood cholesterol
* reducing risk - physical, mental and social activities
* genetic - abnormalities on chromosome 1, 14 or 21
79
describe vascular dementia
* caused by reduced blood flow to brain which damages and eventually kills brain cells
* can be caused by - small vessel disease, single large stroke, lots of mini-strokes, high BP and diabetes, lifestyle factors such as smoking
* distinctive features - memory problem of sudden onset, visuospatial difficulties, seizures, delusions
80
describe dementia with lewy bodies
* deposits of abnormal protein called lewy body inside brain cells
* also found in people with parkinsons disease
* build up in areas on brain responsible for things such as memory and muscle movement
* distinctive features - short term memory loss, cognitive ability fluctuates, overlapping motor disorders, sleep disorders
81
describe frontotemporal dementia
* changes in personality and behaviour, and difficulty with language
* frontal lobes deal with behaviour, problem solving, control of emotions
* younger age of onset
* TDP-43
* distinctive features - short term memory loss, uncontrollable repetition of words, personality change, mutism
82
what genes increase risk of alzheimers
* genes from a group called ApoE
* arent any good genetic tests that can predict alzheimers
83
early stage symptoms of dementia
* loss of short term memory
* confusion
* poor judgement
* unwilling to make decisions
* anxiety or distress over percieved changes
* often mistaken for stress, bereavement or normal ageing
84
middle stage dementia symptoms
* more support required - reminders to eat, wash etc
* increasingly forgetful - may fail to recognise people
* distress, aggression, anger
* risks include wandering and getting lost, leaving taps running etc
* may experience hallucinations
85
late stage dementia symptoms
* inability to recognise familiar objects, surroundings or people
* increased frailty
* difficulty eating
* weight loss
* incontinence - unintentional passing of urine
* gradual loss of speech
86
how is dementia diagnosed and measured
* dementia screen to eliminate treatable causes - kidney, liver, thyroid function tests
* MMSE - neurological examination and detailed cognitive testing
* mini mental state examination
87
mini mental state examination
pros and cons
* pros - well known , easy, samples range of cognitive functions
* cons - only 3 words to be remembered on recall so not sensitive to mild impairment, non standardised time between registration and recall, not sensitive in testing frontal lobe
88
dementia treatment
* no pharmacological, surgical or behavioural cure
* counseeling may delay residential care by up to 1 year
* reducing cardiac risks may decrease deterioration of vascular dementia
* NSAID and vitamin E may slow progression
89
examples of SCD groups
* learning disability
* physical disability
* mental health problem
* homelessness, refugee and asylum seekers
* medical compromise
* older people
* pts requiring behaviour management techniques
90
define handicap
* disadvantage for a given individual
* resulting from an impairment or disability
* that limits or prevents the fulfilement of a role that is normal for that individual
91
SCD barriers to care
* fewer visits and longer intervals between
* limited access to buildings
* difficulty communicating pain
* financial
* emergency care rather than planned
* treatment with GA
92
SCD key legislations
* the human rights act 2000
* the equality act 2010
* the adults with incapacity act (scotland)
* the mental capacity act (england and wales)
* NHS terms of service
* GDC
93
common things SCD see
* late presentation and severe levels of disease
* xerostomia
* infections
* mucosal disease
* malignancy
* infected osteoradionecrosis ORN
* MRONJ
94
define impairment
* any loss or abnormality of psychological, physiological or anatomical structure or funtion
* considered to occur at level of organ or system function
95
define disability
* restriction or lack of ability to perform an activity considered normal for a human being
* disability is activity restricted by impairment
* functional performance or activity, affecting the whole person
96
disability in the equality act definition
* having physical or mental impairment that has a substantial and long term negative effect on your ability to do normal daily activities
* long-term - likely to last at least 12 months but specific rules for recurrent or fluctuating conditions
97
function of the equality act 2010
* legally protects people from discrimination in the workplace and in wider society
* provides a legal framework to protect the rights of individuals and advance equality of opportunity for all
* protected characteristics
* places a legal duty on organisations to make reasonable adjustments to reduce the barriers that may affect people accessing care
98
protected characteristics
* age
* disability
* gender reassignment
* mariiage or civil partnership (in employment only)
* pregnancy and maternity
* race
* religion or belief
* sex
* sexual orientation
99
types of discrimination
* direct discrimination - treating someone with a protected characteristic less favourably than others
* indirect discrimination - putting rules or arrangements in place that apply to everyone but puts someone with PC at an unfair advantage
* harassment - unwanted behaviour linked to PC that creates offensive environment
* victimisation - treating someone unfairly because they have complained about discrimination or harassment
100
inverse care law
* The inverse care law is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served
* those who most need medical care are least likely to receive it
* those with least need of health care tend to use health services more (and more effectively).
101
define reasonably adjustments
* making adjustments to reduce barriers that may affect people accessing care
* change the way things are done
* change a physical feature - add ramp if stair access
* provide extra aids or services
102
overcoming barriers
5 domains
* accessibility - physically and practically accessing care
* accomodation - refers to relationship between organisation of services and pts needs
* affordability - cost is barrier to healthcare
* acceptability - when adjustments are made must be acceptable for pts with disabilities
* availability - lack of suitable available services - prolognued wait lists and high demand etc
103
what is advocacy
* advocate is a person to supports pt to help express their views and wishes
* advocates can be helpful when people find it difficult to make their views known or need other people to listen and take their views into account
104
patients right act
* gives everyone the right to recieve healthcare that :
* considers their needs
* considers what would most benefit their health and wellbeing
* encourages them to take part in decisions about their health and wellbeing
105
detention and CTO
* emergency detention certificate allows a person to be held in hospital for up to 72hours while their condition is assessed - only takes place when doctor reccommends and mental health officer should agree to it if possible
* short term detention can only take place if recommended by psychiatrist and a mental health officer
* CTO - compulsory treatment order allows for a person to be treated for their mental illness
106
social vs medical model
* social model - people are disabled by barriers in society / social organisation that takes little or no account of people who have impairments and/or creates segregated and second-rate provision (eg segregated education and leasure facilities)
* medical model - says people are disabled by their differences or impairement and should be 'fixed' or changed by medical tx
107
barriers to social model
* segregated social provision
* inflexible procedures and practices
* inaccessible information
* inaccessible buildings
* inacessible transport
* negative cultural representations
108
causes of learning disability
* preconception - parental genotype, maternal health
* pre-natal - chromosomal genetic, infection, maternal health, nutrition, toxic agents
* preinatal - prematurity, injury
* postnatal - infection, trauma, toxic agents, nutrition, sensory social deprivation
109
syndromes associated with learning disability
* downs syndrome
* prader willi syndrome
* autism spectrum syndrome
* willaims syndrome
110
what is downs syndrome
* neurodevelopmental disorder or genetic origin affecting chromosome 21
* most commonly due to 3 copies of chromosome 21
* small number of cases (2-4%) due to mosaicism - occurs when a person has two or more genetically different sets of cells in his or her body
111
downs syndrom medical features
* growth failure
* intellectual impairment
* alzheimers dementia
* epilepsy
* leukaemia
* hearing impairment
* diabetes mellitus
* broad flat face, short nose
* congenital heart disease
112
what is prader willi
* syndrome which affects chromosome 15
* learning difficulties
* restricted growth
* lack of sexual development
* behavioural problems such as tantrums or stubbornness
* constant desire to eat food
113
downs syndrome dental considerations
* oral hygiene difficulty
* oral function
* saliva
* periodontal pathogens
* immune system related factors - upregulated production of inflammatory mediators
* impaired migration of gingival fibroblasts
114
autism spectrum disorder
* complex developmental condition
* Autistic people may:
** find it hard to communicate and interact with other people
find it hard to understand how other people think or feel
find things like bright lights or loud noises overwhelming, stressful or uncomfortable
get anxious or upset about unfamiliar situations and social events
take longer to understand information
do or think the same things over and over*
115
ASD dental challenges
* sensory atypia may pose a barrier to tx
* many autistic individuals are hypersensitive to stimuli such as bright lights, noise and touch
* toothbrushing and prevention has multiple sensory triggers
116
intellectual impairment
barriers to oral healthcare
* access
* individual characteristics
* pain recognition
* attitude, skills and knowledge of staff
117
intellectual impairment
individual characteristics which could be a barrier to oral healthcare
* not understanding importance of toothbrushing
* sensory problems - doesnt like being touched
* limited communication - pain recognition difficult
* limited mobility
* behavoiur that makes it hard for someone to support oral care
* anxiety major factor
118
cerebral palsy
* neurological condition that affect movement and co-ordination
* muscle stiffness, weakness or floppiness (hypotonia)
* random and uncontrolled body movements
* does not necessarily mean you have a learning disability
119
intellectual impairment
signs and symptoms that a person may be in pain
* aggression directed towards themselves or others
* changes in body language
* altered facial expression
* change in behaviour such as tearfulness, irritability or withdrawl
* changes to appetite
* changes in sleep patterns
* confusion
120
intellectual impairment
adjuncts to communication
* makaton
* picture boards
* letter boards
* talking mats
* draw
* write
121
clinical holding guidelines 2010
* considered if failure of other techniques
* should only take place if - pt consents
- if pt has no capacity and is deemed of benefit
- unplanned emergencies
- aways record and justify
122
intellectual impairment
social history
* living arrangements
* support
* transport
* likes/dislikes
123
mild learning disability dental probelms
* generally managed within primary care setting
* more likely to have filled teeth, fewer extractions and more untreated active decay than adults with increased disability
* dental care appears to be related to cooperation with tx
124
dental risk factors for those with larning disability
* frequent sugar intake
* medications that can reduce saliva flow or increase gingival inflammation
* GORD
* lower income and educational levels
* difficulty accessing dental services
* being non-oral feeders
* reduced dexterity - ineffective TB
* difficulty understanding importance of daily oral care
125
intellectual impairment
prevalence of oral disease
* higher levels of periodonral disease
* higher number of missing teeth
* increased rated of edentulism
* higher plaque levels
* greater unmet oral health needs
126
intellectual impairment
toothbrushing advice
* explain first
* ensure good time of day for pt - relaxed
* stand behind and slightly to one side
* keep brushing systematic
* encourage person to do as much as possible
127
self injurous behaviour examples and can be linked to
* self biting of hands, arms, lips and tongue
* cerebral palsy
* autism
* tourettes
128
drooling causes
* abnormalities in swallowing
* difficulties moving saliva to back of the throat
* poor mouth closure
* jaw instability
* tongue thrusting
129
erosion advice
* fluoride mouthwash unless swallowing difficulties
* toothpsate which is low abrasion, high F
* brushing delayed at least 1 hour after consuming food/drink
* professional fluoride application
130
intellectual impairment
behavioural management
* acclimatisation
* tell, show, do
* relaxation
* structured time - can work well for ASD
131
intellectual impairment
options available for sedation
* inhalation sedation - nitrous oxide
* intra-nasal
* intra-venous - medalizam
* oral - diazepam
* GA
132
intellectual impairment
indication and requirement
* indication - clear inability to co-operate with other tx techniques including sedation or contraindications to sedation
* requires - full history and consent, anaesthetic assessment prior to tx
133
GA risks
* death 1 in 100,000 - 1 in 200,000
* risk increases with age, complexity of surgery, health before procedure
* brain damage
* nausea and vomiting
* confusion and memory loss
* anaphylaxis
* bruising and soreness
134
GA can be best way to provide care if
* significant volume of tx
* pt is unccoperative
* signicant medical complexity is evident
* GA tx aim to make oral health stableand decrease risk of symptomatic disease in 2-3years following - minimising need for repeat GA
135
GA tx plans
* no crowns or bridges unless can be placed without GA
* no endo tx
* infected teeth are removed
* teeth of poor prognosis may be removed
* opposing non functional teeth may be removed
* all tx at 1 episode of care
136
sensory impairment defintion
* when one or more of a persons senses is no longer normal
* a person does not have to have full loss of a sense to be sensory impaired
137
sensory impairment key care needs
* communication
* accessing services
* mobility
* rehabilitation
138
leading causes of visoin impairment and blindness
* uncorrected refractive errors
* cataracts
139
classification of distance vision impairment
* mild - presenting visual acuity worse than 6/12
* moderate - presenting visual acuity worse than 6/18
* severe - presenting visual acuity worse than 6/60
* blindness - presenting visual acuity worse than 3/60
140
symptoms of visual impairment
* severe, sudden eye pain
* hazy, blurred or double vision
* seeing flashes of light or bright floaing spots
* swollen, red eyes
* changes in colour of the iris
* any sudden change in vision
141
describe cataracts
* clouding of the lens of the eye - prevents clear vision
* majority related to ageing process
* leading cause of blindness
* can be surgically removed
142
describe age-related macular degeneration
* loss of a persons central field of vision
* affects older people
* occurs when macular (central) retina develops degenerative lesions and cells become damaged or scarred
* several forms of AMD exist - wet ; dry
* wet causes severe sight loss in matter of months - growth of new blod vessels under retina which break and leak blood and fluid into macula
* dry is bilateral condition 90% cases gradual loss of central vision
143
types of visual impairment
* cataracts
* age-related macular degeneration
* glaucoma
* diabetic retinopathy
* hemianopia
144
decribe glaucoma
* optic neuropathy which is determined by both structural change and functional defecit
* usually caused by fluid building up in front part of eye which increases pressure in eye - rise in intraocular pressure
* generally bilateral condition - affects one eye before the other
145
describe diabetic retinopathy
* lesions found in the retina of individuals having had diabetes mellitus for several years
* result of vascular changes in retinal circulation
* can result in macular oedema
146
diabetic retinopathy risk factors
* duration of diabetes
* level of glycemia
* presence of high blood pressure
* dependence on insulin
* pregnancy
* genetic factors
147
causes of diabetic retinopathy
* continuous high blood sugar levels cause BV to become blocked or leaked
* damages retina usually in 3 main stages
1. background retinopathy - tiny bulges in BV develop does usually affect vision
2. pre-proliferative retinopathy - more significant BV changes including bleeding into eye
3. proligerative retinopathy - scar tissue and new BV and weak and bleed easily develop on the retina
148
decribe hemianopia
* blindness in one half of the visual field
* stroke most common cause
* is a functional defect which can affect the left or right side
149
visual impairment prevention
* regular eye exams
* protect eyes from the sun
* protective eyewear at work
* know family history
* stop smoking
* seek tx quickly
150
maximising communication for people with visual impairment
* always identify yourself
* keep pt informed of people moving around
* tell them what youre doing before you do it
* do not use non-verbal communication
* provide info in alternative formats - eg CD, extra large print, braille
* allow extra time
151
define heating impairment
* person who is not able to hear as well as someone with normal hearing
* threshold of 25dB or beter in both ears is said to have hearing loss
* may be mild, moderate, severe or profound
152
causes of hearing impairment
* congenital - low birth weight, birth asphyxia, maternal infections during pregnancy, inappropriate drug use
* severe jaundice in neonatal period
* infectious disease
* chronic ear infections
* otitis media - collection of fluid in ear
* injury to head or ear
* recreational exposure to loud sounds
* wax or foreign bodies blocking ear canal
153
signs of hearing impairment
* failure to respond to sound
* deterioration of speech
* confusion
* withrawl
* speaking in unusually loud voice
154
hearing impairment maximising communication
* ask if they want to use a loop system
* try establish pts preferred communication method
* book BSL interpreters etc if necessary
* use finger spelling
* write things down
* allow extra time
* use clear speech, normal lip pattern, dont shout
155
elderly common issues
* frailty
* polypharmacy
* continence - not in control of bladder/bowl
* falls
* bone health
* nutrition and weight loss
156
frailty definition/phenotype
* state of increased vulnerability due to age related declines in physiological systems - neuromuscular, metabolic, immune
* unintentional weight loss
* exhaustion
* weakness - measured by grip strength
* low physical activity
* slow walking speed
* presence of 3 or above = frail
* 1 or 2 = pre=frail
157
defining oral health
* many features
* ability to speak, smile, smell,, tase, chew, swallow, convey emotions through facial expressions
* with confidence and without pain, discomfort and disease free
*
158
oral health
what improves quality of life
* more natural teeth
* occluding pairs
* implant retained dentures
* chewing ability
159
oral health
what decreases quality of life
* anterior spacing
* missing teeth
* no functional dentures
* dry mouth
* orofacial pain
* caries and perio - no clear consensus
160
whats the name of scotlands national oral health promotion for elderly
caring for smile
161
what is caring for smile
* scotlands oral health promotion, training and support programme
* for adults who move into care homes
* have their mouth care needs recorded in thier personal care plan
* supported to clean their teeth twice a day or undertake daily oral care for dentures
162
end of life trajectories
* sudden death
* terminal illness
* organ failure
* frailty
163
to treat or not to treat elderly pt
* predicting how long pt is going to live is challenging
* is tx good use of their time
* does tx improve qualty of life
* if dentists know pt is in end stages of life they conform to a more conservative approach
164
importance of oral care in elderly
* health
* nutrition
* quality of life
* communication
* appearance
* ageing population
165
caring for smiles key messages around
* oral health education - understanding importance
* oral care for dentate patients
* diet and nutrition education
* oral care for denture wearers
* denture care
* oral care for patients with dementia
* oral care for end of life
* how to spot changes in the mouth - oral cancer
166
tools ant techniques to help when residents find oral care difficult
* time and place - develop routine, well known staff to resident, quiet distraction free environment, sufficient light
* be caring, calm friendly and smile
* talk clearly at residents pace
* explain in short sentences (simple terms) what you are doing
167
if resident shows reluctance to oral care - other strategies
* bridging - show resident TB and have them mirror your behaviour and brush own teeth
* chaining - gently bring residents hand to mouth whilst describing activity
* hand over hand - place hand over residents and gently brush together
* distraction - place familiar item in residents hand while brushing residents teeth
* rescuing - if attempts not going well carer can leave and someone else takes over
168
special consideration sub group for risk of infective endocarditis
* pt with prosthetic valve or prosthetic material used for cardiac valve repair
* pt with previous episode of infective endocarditis
* patients with congenital heart disease - cyanotic CHD, CHD repair with prosthetic material
169
stage of dementia affecting tx plan
describe early dementia
* loss of short term memory
* confusion, poor judgement
* unwilling to make decisions
* anxiety or stress over percieved changes
* communication problems
170
stage of dementia affecting tx plan
describe middle stage dementia
* reminders to eat, dress and use loo
* increasingly forgetful - may fail to recognise poeple
* mood changes
* risk of wandering and getting lost, leave taps running, cooking unattended etc
* may behave inappropriately - going out in nighclothes etc
* may experience hallucinations, throwback memories
171
stage of dementia affecting tx plan
describe late stage dementia
* inability to recognise familiar objects, surroundings or people
* increasing frailty
* difficulty eating and swallowing
* incontinence and gradual loss of speech
* symptoms are progressive and irreversible
172
oral medicine problems in elderly
* haemangioma
* fibroepithelial polyp
* black hairy tongue
* geographic tongue
* atrophic glossitis
* frictional keratosis
* sublingual keratosis
* speckled leukoplakia
* denture related problems
* angular chelitis
* xerostomia
* lichen planus
* oral cancer
* burning mouth syndrome
173
oral medicine problems in elderly
haemangioma
* collection/malformation of blood vessels
* if traumatised they will bleed
* any site of mouth - often lip, edge of tongue
* can increase in size
* removal should be done in hospital setting due to risk of bleeding or in oral surgery via cryo
174
oral medicine problems in elderly
fibroepithelial polyp
* "skin tag"
* growth where mucosa looks the same as surrounding
* can be due to trauma - instead of healing there is build up of tissue
* sessile (attached by broad base or on a stalk)
* as theygrow its trickier to remove and can be ulcerated as they rub against teeth
175
oral medicine problems in elderly
black hairy tongue
* overgrowth on surface of tongue - dead cells? bacteria?
* picks up stains from tannins - tea/red wine etc
* nothing to worry about
* can become unpleasant - aesthetically and can smell
* more common in smokers
* very difficult to get rid of
* to clean go from midline forwards NOT back as dont want to push bacteria down throat
* gentle circular motions with toothbrush or tongue scraper to remove excess staining etc
176
oral medicine problems in elderly
geographic tongue
* erythema migrans - areas of atroph surrounded by a white slightly raised margin
* 10% population have this
* and 10% of those who have it have a degree of sensitivity to spicy or citrus foods
* areas change in shape size and location over time
177
oral medicine problems in elderly
atrophic glossitis
* really smooth tongue
* most common cause - low iron levels or low vitB12 levels
* can be very uncomfortable
* if iron levels drop further and cause ulceration - very difficult to tx
* if you see ask GMP to do routine haematinics or bloods
178
oral medicine problems in elderly
frictional keratosis
* white patch
* due to trauma and keratinisation -sharp tooth/filling etc
* if you cannot find a traumatic cause always review for healing
179
sublingual keratosis
* could be leukoplakia
* intra-oral soft tissue exam so important
* high risk site for something unpleasant to lurk
* if crosses midline OM referral
180
oral medicine problems in elderly
speckled leukoplakia
* hyperplastic candidosis
* speckled appearance - often angle of mouth/commissure
* can be uni or bilateral
* common in smokers
* pre-malignant lesion so has to be monitored
* initially a microbiological swab to check for candida then biopsied - refer to oral med
181
oral medicine problems in elderly
denture related problems
* traumatic keratosis
* denture induced hyperplasia
* denture induced stomatitis
182
oral medicine problems in elderly
denture induced hyperplasia
* common in elderly - more common with lower dentures
* rubbing at sites leads to an overgrowth - flaps of tissue as mouth tries to protect itself
* best tx is to remove denture entirely - new denture/adjust denture
183
oral medicine problems in elderly
denture induced stomatitis
* very common and generally painless
* candidal infection - hypahe burrow into mucosal surface and denture
* erythema on palate
* ask pt to remove denture at night and soak denture
184
oral medicine problems in elderly
angular chelitis
* mixed bacterial/fungal infections at corner of mouth
* difficult to heal
* often caused by denture acting as reservoir for bacteria and fungi
* take bloods - investigate low iron, vit B12, folate etc
* in elderly pt face sags - wet skin folds - moist painful area
185
oral medicine problems in elderly
xerostomia
* dry mouth
* causes - polypharmacy, sjrogens syndrome, radiotherapy to head and neck
* management - change medication, salivary replacement, salivary stimulants
186
xerostomia salivary replacements
* saliva orthana
* glandosane
* biotene oral balance
* bioXtra
* salivary stimulants - chewing gum, glycerine and lemon
187
oral medicine problems in elderly
topical drug reactions
* two main drugs - iron and aspirin
* aspirin burn - burns mucosa
* iron tablets will also burn mucosa if in contact
* if difficulty swallowing should be given liquid iron
188
lichen planus and lichenoid tissue reactions summary
* mucocutaneous disorder affecting oral mucosa
* lichenoid reaction more common (mimics LP) caused by reaction to certain drugs - NSAIDs, beta blockers etc - not as result of autoimmune condition
* lichen planus is dermatological condition - oral or skin/genital - white striae often on BM, lips, rare on palate
189
oral medicine problems in elderly
lichen planus
* chronic inflammatory condition affecting the skin and mucosal surfaces - believed to be due to autoimmune reaction
* in mouth many subtypes - reticular, erosive, atrophic
* erosive can be painful - see OM
190
bisphosphonate uses
* non malignant: osteoporosis, pagets disease, osteopenia, primary hyperparathyroidism, osteogenesis imperfecta
* malignant: multiple myeloma, breast cancer, bony metastatic lesions
191
what is sequestrae of bone
piece of dead bone that has become separated during the process of necrosis
192
MRONJ risk factors
* bisphosphonate use
* extremes of age
* concurrent use of corticosteroids
* systemic conditions affecting bone turnover
* malignancy
* chemo-radio therapy
* duration of therapy
* invasive tx - anything that manipulates the bone
193
MRONJ pt advice
* advise patient of MRONJ risk
* informed consent
* emphasise rarity of condition
* dont discourage from taking meds
* regular dental checks
* maintain good OH
* limit alcohol and stop smoking
194
oral medicine problems in elderly
herpes zoster
* also called shingles
* varicellar zoster virus reactivation
* can affect any branch of trigeminal nerve
* often unilateral and in older pt
* starts with predromal rash - 2-3 days later unilateral rash on face and in mouth
* very painful
195
oral medicine problems in elderly
poste herpetic neuralgia and tx
* previous episode of shingles
* constant burning sensation in dermatomal distribution
* 50% resolve in 2 months
* may persist 2+ years - suicide risk
* tx - antidepressants, carbamezapine, TENS
196
oral medicine problems in elderly
trigeminal neuralgia overview
* more common in females and in maxillary/mandibular branches
* described as electric shock sensation
* not there constantly
* can be triggered by shaving, smiling, biting, touching face
197
oral medicine problems in elderly
trigeminal neuralgia medical management
* carbamezapine - one of few liscenced drugs for this condition - start low dose and gradually build
* gabapentin
* pregabalin
* should be managed by OM
198
oral medicine problems in elderly
trigeminal neuralgia surgical management
* peripheral procedures: cryotherapy, injection of alcohol or glycerol, neurectomy, avulsion of nerve
* gangion procedures: balloon compression, microvascular decompression
199
oral medicine problems in elderly
burning mouth syndrome
* more common in females
* can be linked with anxiety and depression underlying
* mouth appears healthy but is painful and uncomfortable to pt
* all pts get FBC, haematinics - folate, ferritin, vitB12 and glucose
* generally no cause identified
* may lead to malnutrition, slow recovery, reduced QoL
* causes - no cause 50%, psychogenic 20%, dry mouth, candidosis, haematinic deficiency, allergy
200
oral medicine problems in elderly
oral cancer
* should be top of our minds when assessing any pt
* can have ulcerated base and heaped up margins
* neglected mouth not atypical presentation
* can also be speckled lesion
* when in doubt refer
201
life course of a dentition
* primary dentition
* secondary dentition
* partially dentate
* edentulous
202
challenges of the ageing population
* increased number of people with long term conditions
* increase in co-morbidities - cardiovascular disease and stroke, cancer, diabetes COPD
* polypharmacy
* not enough working adults to economically support adults
203
impact of ageing on systemic disease
* increased risk of oral disease
* polypharmacy
* impaired ability to cooperate
* decreased access - moving and handling
* may complicate dental tx or contraindicate dental tx
204
head and neck cancer of older people in care homes
* usually present with more advanced disease at assessment
* early assessment, diagnosis and management are essential
* symptoms may unable to be communicated
* 1/5 diagnosed occur in people 75+
205
aspiration pneumonia most common with
* dysphagia
* associated with neurological impairment
* 18% nursing home aquired
* 5% community acquired
* pts with feeding tube increased risl
* oral bacteria main source of infection - poor oral health increases bacterial load and risk
206
tx to provide in dementia
early stage
* planning for future
* assessment
* identify and attempt to retain key teeth
* focus on high quality restorations
* establish a preventative regime
207
tx to provide in dementia
mid stage
* maintenance and prevention are essential
* ability to co-operate may deteriorate - limiting ability to provide intervention
* access becomes increasingly more challenging
208
tx to provide in dementia
late stage
* focus on comfort
* moist clean and healthy mouth which is free of pain and infection
* non-invasive
* emergency management - limited options
209
elderly pt
dentally controllable factors
* oral hygiene and removal of biofilm
* sugar
* level and quality of care
* teeth
* fluoride
* operative intervention where indicated
210
elderly pt
risk factors for restoration failure
* lower number of toothbrushing/day
* absence of prosthesis
* posterior location of the tooth
* higher baseline plaque index
211
what did the francis report reveal
* reports of abuse and neglect
* not an isolated incident - many hospitals with similar reports
* accepted behaviour and "the norm"
* resistance to change
212
older pts
staphylococcal mucositis
* microbial testing demonstrated staph. aureus
* build up of dead mucosal cells, dried mucous and salivary secretions
* scab like lesions due to lack of oral care
213
older person symposium
barriers to pt centred oral care
* oral health is low priority in care plans
* carers have limited knowledge on oral health
* carers have difficulty in gaining access to residents teeth
* high turnover of care staff
* poorly paid care staff
214
older person symposium
oral and general health link
* pain free and comfortable
* nutrition
* risk of life threatening spread of oral infectrion
* infection can smell and taste unpleasant
* inhibiting social interaction and decreased wellbeing
