Special care - revision notes Flashcards
What is warfarin
warfarin is a Vit K antagonsit that works by blocking the clottiginfactors essential for forming a clot.
These are clotting factors , 2, 7, 9, 10 and protein C and S
INR
international normalised ratio - measures the time for the blood to form a clot
Prothrombin time/referecne partial thromboplasatin time
PT is esseintial for forming a clot
INR for healhty people
= 1
INR for people on warfarin recienving tx
INR <4 and stable
Stable INR
<4 and has been for the last 2 months
does not require weekly monitoring
Stable INR
tests 72 hrs before the procedure
Why are people on warfarin
Atriral fibrilliation
MI
Blood clots in veins (venous thrombosis)
Blood clots in lungs (pulmonary embolism)
Low risk dental procedures
6PPC
examination
radiographs
simple XLA
RSD
direct resotrations
High risk dental procedures
Biopsies
Rasing flaps
Gingivectomy
Extensive or complicated XLA’s
Apixiban
a direct noval oral anticogulatn that works by inhibting factor Xa which works by blocking the action of activated factor xwhich is needed for forming a clot
taken x2 daily
Dabagratran
a direct inhibotr of the factor thrombin
taken x2 daily
Rivaroxaban
taken once daily
Apixaiban and dabagratran
delay morning does till haemostasis has been achied >4hrs after tx
Treatment if on warfarin
> 4 then delay treatment
early morning and week appts
haemostasiis agents ready
XLA no more than 3 teeth at one time
paracetamol instead of NSAIDs
Thrombin
convereted from prothrombin
serine protease
thrombin then converts fibrnogen to fibrin
Cogualtion casacade
for a clot to form need to activate proteins called clotting factos
- intrinsic - activated by factors in the blood (factor VII)
- extrinsic - activated by factors in the tissues
common - both theses pathways results in the activation of the common and facto X which converts fibrnogen to fibirn to form a clot
MDT for head and neck cancer
oncologist
chemo nurse
speech and language therapsit
physio
patholoigist
surgeon
speacial care dentist
Risk factors for oral cancer
smoking
acohol
betal quid
nutrtion - low in antioxidantes
Socieconmic factors
poor OH and dental health
HPV
High risk sites for oral cancer
ventral and lateral borders of tongue
buccal mucosa
floor of mouth
hard and soft palate
orpharynx
Signs and sympomts
horseness in voice
persient ulcer with unknown casues for >3wks
red or white patches in mouth >3weeks
ear pain with no ear abnormalities >3wks
persistent soreness
unexpailed lump >3wks
Clinical signs of oral cancer
solitary ulcer
raised with rolled margins
firm base and hard
erythema
Pre malgingant conditions
Leukoplakia
erythroplakia
lichen planus
palatal keratosis
squamous cell carcinoma
submucosous fibrosis
Mucosistis
inflammation and ulceration leading to pain
7-14 days after drug therapy
tx for mucositis
avoid spicy acidic food, spirits and tea
smoking avoid
soidium bicarb, tea tree oil , honey, CHX, gelclair, saline
chew on ice cubes
oral cooling ice
morphine/;laser light therapy
Radiotherapy
dose and field of tx
side effects - trismus, loss of taste, dry mouth, oral ulcers, incrseased risk of candiodsis, burning mouth, caries, osteoradnecrosis
Side effects of chemo
naseua vomiting, diarrhea
mucossitis
mouth sores dry mouth, tooth decay, bleeding
infection risk incrseaed
hair loss
fever
loss of apeptite
Chemo blood tests
white blood cells decrseased,
RBC
Platelets
Neturopenia
leukopenia
Radiation induced caries
caries that occurs at the neck of teeth due to the radiation damage casued by the radiotherapy
tx - primary rothograde surgery and decorniate
Osteoradionecrosis
damage of bone jaw
Post radio and chemo
mainitain regular dental exams
OHI and maintain good OH
High lfurodie toothpaste
Fluoride varnish
tooth mousse
saliva stimulants to help with dry mouth
stop smoking
CT vs MRI
CT - shows soft tissue and bone, quick and no claustrophibia for pt, however need blood tests to check kidneys before commening as iodine die can cause issues with kidney probs in people, small radiation risk
MRI - shows only soft tissues, non invasive, no radiation exposure, no iodine die causing issues
However - expensive, claustrophibia, takes time to do, difficult if have metal devices in body
Osteoradionecrosis
can hapen to a person after recieving radiotherapy for oral cacner
>60 grays
Signs and symptoms - pain, ulcers, sores, trismus, exposed bone, sharp pieces of bone, swelling, infection, sequestrum
Dentists before radio - remove all teeth with poor prognosis, liase with oncologist, commence all tx 10-14 days pre radio
Post radio and need tx - mayrequire hyberpbaric oxygen befroe tx
Osteroradnecrosis occurs - remove necrotic tissues, irrigation with saline, CHX mw and remove and smooth shrap edges,
only prescribe antibiotics if secondary infection occurs
Signs of oral cacern
solitary ulcer
firm and hard
raised rolled margins
erythema
Incapable means
acting
making decsion
retaining decion
understanding decision
communicaigndecsion
Who can issue a certificate of incapcity
medical practioner incharge of persons care
registered nurse
consultant in charge of pt care
dentist if specilaist training
Guardianship orders
when the person has no capacity
if have joint guardianship just need consent form 1
court appointed
requires 2medical reports
appoitned for 3years
deals with finance, proterty and martia affairs
Adults with incapacity act 2000 0or mental health act 2004 (england)
to protect people who lack capacity to make decsions and support involement in making decsions
Principles of adults with incapcity 2000 act
Beenfit
minimal intervention
takes into the wishes of the the adult
consultation with relvant others
enourages the audult to exercise residual capacity
Power of attornery
granted by the adult when thet still have capacity
certified by lawyer or by medical practioner (proxy)
Welfare - comes into affect when person incapable of making decision, realating to health and personal
Continuing power - fincial and property affairs only
Local casues of pseudomembraous candidosis
dentures - ill fitting dentures
antibiotcs
xerostomia
cortocisteriod use
General casues of psedomembranous candidosis
smoking
diabetes
cushings
iron deifiency
drugs
HIV
immunoompromised
Diseases that causes xerstomia
diabetes
radio/chemo
sjogren’s syndrome
RA
cystic fibrosis
parkinson’s disease
hyperpathyroidsm
Drugs casuing xertstome
beta blockers
antircylic antidepressants
anti convulsants
anti pysiochitoics
NSADS - diclofenac
direuetics
protein pump inhibitors
antohistamines
Casues of ulcers
trauam - chemical, mechanical, thermal
carcinoma
vesicubullous diseases - pemphgoid, pemipgisu
viral infections - HIV
GI diseases - crohns, UC, coliac
autoimmune diseases - OFG
meds - iron tabs, ,aspirn
Xerostomia
unstimulated salvia flow <0.3ml/min
Risks of xerostomia
increased caries and perio risk
difficult swallowing
difficlut with speaking
difficult eating and chewing food
bad taste
burning mouth
candidosis
ulcerations
angular chelitis
sialodentitis (infection of salivary gland)
Reasons for hypersalivation
meds -prilocarpine
disabilites - cerbral palsy
anxiety or stress
psycholocial
stroke
parkinsons
Preganant
MDT for dementia
hospice staff
care home nurses
GP
consultant
pharmacy
community nurses
Dementia friendly care homes
toilet visible from bed
walls, floor and sceiling different colours
labelled cupboards and drawers
radiator low temp
personal pics
furniture tradiotional and domestic
Dementia friendl in dental setting
natural light
reception desk visible from entrance
avoid non essential signs
locks rooms same colour as walls to direct attention away from them
pictorial elements
simple text and colour
singange eye level
Diseases casues xerostomia
Diabetes
Hyperpathyrodism
HIV
Cushings syndrome
sjoren’s syndrome
RA
parkinson’s
cystic fibrosis
radio and chemo
Drugs causing xerostomia
duretics
antihistamines
anti cyclic depressants
protein pump inhibiors
beta blockers
anti-covulsants
anti-psychiotics
NSAIDS -diclofenac
Dementia
detoriation in cognitivie function beyond what is normal for aging
Dementia affects
memory
thinking
oritentation
calculation
lanuguage
comprehension
learning capacity
Frontal tmeporoal dementia
Dementia of prtein TDP-43 associated with clumps of protein
tends to occurs in younger pts with change of personailiyt and difficult with language
Dementia with lewy bodies
when desposits of prteins (lewy bodies) are abnormal inside the brain
Vascualr dementia
reduced blood flow to the brain
tends to occur in people who are overwegith, diabetes, smoker, high BP
Alzehermier dementia
reduction in size of the cortex - deposists of plq in the brain cells - amyloid plqs
Testing for demetnia
detailed cognitive testing
mini mental state exam
blessed dementia scale
FBC, U&E’s, urinalysis, liver, kidney, glucose, serum, folate, calcium, protein
Heamophillia acquired or inhertitied
acquired bleeding disorder
Name types of acquired bleeding disorders
protein cdefiecnecy
protein s deificency
von willebrand
Haemophillia A
Haemophillia B
Inhertited bleeding disorders
trauma
preganancy
cancer
surgery
OCP
Haemophillia A
X lineked recissive acquired bleeding disorder
defieicnecy in VII
Haemophillia B
x linked reciessve acquired bleeding disorder
defeicney in factor IX
Von willebrand
autosomal dominant (both affected)
factor VII levels are reduced
reduced platelet aggregation
Grading severity of heamophillia
mild = 6-40% factor present
mod = >2.5% factor present
severe <1% factor present
Safe procedures for heamophillia
supra ging scaling
exams and radiographs
LA inf
articaine INF
supra ging restorations
Risky dental procedures for heamophillia
sub ging scaling
XLAs and surgicals
biopsies
IDB or lingual inf or superior nerve block
MOD and severe grading heamophillia
carried out in haemophillia clinic
Thrombophillia
incsread risk of clots developing due to lack of protein causing the body to be unable to clot
acquired
Tx for heamophillia
mild Haemophillia A and von willebrand - tx with DDAVP which release factor 8 (do not use for heamophilllia B need a recombineent facotr IX)
severe = tranxiamic acid which is an anti-fbronolytic agent or factor replacement
Throbocytopenia
reduced number of platelets in the blood
due to failure of proteins numbers - anemia, vit defiency
or
platelet destruction - splenogemegaly viral, drugs, autoimmune
Thrombocytopenia
normal = 150 x10^9l-400x10^9/l
dental tx in GDP - >100x10^9/l
consult and liase with heamtolgist <100 x10^9/l
Tests for bleeding disorders
LFT
FBC
Haemophillia and factor screen
Cogualtion screening - prothrombin and activated partial thrmoboplastin time
How to help people with physical disability
electric toothbrush
putty handles
foam handles
ball handles
collis curve toothbrush
Adaptions to dental practice for people with disabilites
designated parking spaces
signposting for sensory impairment
ground level access
designated disable toilets
wheelchair turning circle
hearing loops
handrails for support
wide dorrs and corrodrs
Equality act 2010
protects people from discrimination within the workplace
age, sex, religion, disability, sexual oriteitatin
Disability discrimination act 2004
rights in employment access to goods and facilites
tx for nctsl
flurodie mw’s
flurodie varnish
dentine bonding agents
chew sugar free gum
reduce carbonated drinks and acidic fruits
flurodie varnish
Social model
disbaility caused by how socity is organsied rather than a person’s impairment
Medical model
disability cuased by a persons impairment and differnces should be fixed/changed my medical tx
ways to gain access to mouth
open wide mouth rsts
bedi shields
mirror
good light
toothbrush
clincial holding
Options to aid transfer to chair
hoist
stand aid
wheelchair reclininer
turn table
wheelchair tipper
banaana board
Cerebral palasy
a neurodevelopment conditin affective movement and co-ordination
Dyskinetic - involutanty movements
spastic - muscles tight and stiff
ataxia - shaky movements affects balance
mixed
Dental issues with cebral palsy
difficuty gaining access to the mouth - random uncontrolled movments
sotre food in the mouth
drooling and hypersalivation
increased caries risk
high surgar meds
can’t hold toothbrush in mouth
Prader willi
chromosmoe 15 does not function or not present
constant desire to eat food
restricted growth
reduced muscle tone
lack of sexual devlopment
learning difficuties
behavioural issues
Down syndrome
fall trisomy of 21 - extra copy of 21 chromomsome
Features of down syndrome
flat face
short back of neck
abnormal eara
short brad nose adn hands
round oval face
flat back of head
diminsed muscle tone
Dental features of down syndrome
class 3 malocclusion
AOB
hypodontia
supernumerary teeth
small and arched palate
posterior cross bite
fissure tongue
small lips and opening of mouth
Medical features of down sndyndrome
congential heart defects
alzehmer’s/dementia
eye probles
epilspy
leaukameia
tyrhoid disorder
hearing impairment
colaic disease
depression
sexual health issues
Signs of liver diseases
jaudnince
finger clubbing
aascites
bleeding
spider naevi
oesophageal varices
Casues of liver diseases
infective - hep a,b,c,d,
non finective - primary billiary circihosis, alcohol , non alcoholic fatty liver disease, drug induced, hetocellular carcinoma
Dentistry and liver
do not give lignocaine as metabolised in the liver, use articaine and not blocks as increased risk of heamatoma
avoid IV sedation as prolongs effects and can induce coma
increased bleeding tendeies due to clotting facotrs made in liver
more prone to infection
antibiotics - avoid metro and erythromycin
avoid NSAIDs as unable to metabolise
Bone marrow suppression by hep c
why do liver diseases pts get thrombocytopenia
due to anti cancer agents
reduction in platelets due to reduction in thrmobopoietin which regulates platelet production
bone marrow suppersion by hep C
Dental implications of an eating disorder
NCTSL
xertostomia
senstivity
hostile acidic environment
loss of vertical dimension
Depression dental aspect
TMD problems
poor OH
dry mouth
spots or lumps
chronic facial pain
burning muoth
disturbed taste sensation
Tardive dyskinesia
involuntary movements of the tongue, lip face and trunk
happens in people who recieve antipsychitocis for mainy years
Bipolar disorder
a disorder which affects you rmood swings
manic, depressive, hypomanic
depression - increased decline in oh, incrseased perio and caries risk
mania - overdose use of OH aids and can cause abrasion NCTSL
Pysychosis
lose contact with reality - percieve things differntly to those around them
hallicnations and delusion
types schizophernia - affects how you think feel and behave, hallicinations, delusions, muddled thoughts, losing interest
tx - talking therapies, CBT antipsyhciotic meds,
Bioplar
Psychosis trigger by
stress
meds
alocohl
drug misue
physical condition - eg brain tumour
antipysichiotic mieds
olanzapine
quetiapine
clozapine
Psychosis types
Bipolar
schizophrenia
schizoeffective disroder
Bipolar
mood disorder and swings
1.mainc
2.depressive
3. hypomanic
Schizophernia
hallicinations and delusions
paronoid illusions
muddle thoughts
losinginterest
tx - CBT, antipsyhchotic meds, counselling and psychotherapy
Dental antipsychitoics can casue facial dsykiensia, hypotension, hypersalivation , dry mouth oral pigmentation and extra pyradaminal effects
Extra pyramidal effects
inability to sit still
involuntary muscle contractions
involuntary facial movements
stiff/tremor of muscles
Schizoeffective disorder
bipolar and psychiotic
1. manic - psychiotic and mania
2. depressive - psychotics and depressive
3. mixed
Neurosis
a mild netal health disroder not from organic disease but from stress and anxiety
can be anxiety, depression OCD
Psychosis
a major personality disorder with mental and emtional disruptions
