bariatric care

Question 1

overweight and obese

Answer 1

defined as abnormal or excessive fat accumulation that may impair health.

Question 2

bariatric person

Answer 2

individual of any age (child to adult) who has limitations in health and social care due to physical size, health, mobility and environmental access.

Question 3

obesity deaths

Answer 3

responsible for 3.4 million deaths, has nearly tripled worldwide, contrary to other major global risks (tobacco)

Question 4

projected increase in obese adults in UK by 2030

Answer 4

11 million

Question 5

scottish health survey 2018

Answer 5

65% of adults were overweight;
- 28% who were obese;

68% of men and 63% of women were overweight or obese;

Mental wellbeing was lowest among those within the morbidly obese BMI range;

The annual cost of treating conditions associated ranged from £363 million to £600 million

Question 6

BMI overweight

Answer 6

World Health Organisation defines overweight as a BMI ≥25 kg/m squared

Question 7

BMI Obese

Answer 7

World Health Organisation defines overweight as a BMI ≥30 kg/m squared

Question 8

BMI

Answer 8

defined as weight in kilograms divided by the square of the height in meters.

BMI provides the most useful population-level measure as it is inexpensive, easy to use, the same for both sexes and for all ages of adults.

Question 9

limitation of BMI

Answer 9

Does not assess body fat distribution, because it is a measure of excess weight rather than excess body fat.

Does not account for factors such as age, sex, ethnicity, and muscle mass

Question 10

BMI use

Answer 10

most useful population-level measure as it is inexpensive, easy to use, the same for both sexes and for all ages of adults.

Question 11

contributing factors to obesity

Answer 11

Underlying health problems
- e.g. hypothyroidism in Down’s syndrome and eating issues such as Prader-Willi syndrome (cause excess hunger)

Lack of energy

Difficulty with chewing or swallowing food or its taste or text

Medications that can contribute to weight gain and changes to appetite e.g. steroid medication

Physical limitations that can reduce a person’s ability to exercise pain on movement (e.g. in cerebral palsy, rheumatoid arthritis)

Multiple factors influence including genetics, socioeconomic status, environment and individual decisions play a significant role.

Question 12

fundamental cause of obesity and overweight is

Answer 12

an energy imbalance between calories consumed and calories expended.

Obesity is a complex, multifactorial chronic disease that is strongly associated with multiple comorbidities.
- undernutrition and obesity co-existing.

Question 13

lifestyle factors which contribute to obesity

Answer 13

A lack of healthy food choices;

Accessible environments that enable exercise;

Resources and appropriate social support systems

Question 14

equality act 2010 and obesity

Answer 14

Does not classify obesity as a disability.
- However, conditions associated with obesity may lead to disability.
E.g. wheelchair needed for mobility

Failure to provide suitable safe facilities for bariatric patients has the potential to breach the Equality Act (2010)

Those with disabilities should have the same access to health care as anyone else and it is the responsibility of health care professionals to make reasonable adjustments to aid universal access to our services
- E.g. physical adjustments (alterations to buildings in the form of wheelchair ramps or tactile signage) attitude adjustments (through policies, procedures and staff training, to ensure that services are as accessible for all patients.)

Question 15

role of dental team in bariatric care

Answer 15

Increasing prevalence of obesity within the general population = likely increase in bariatric adults accessing dental services

• Identify oral health issues associated with the bariatric patient.
• Signpost patients to appropriate services e.g Weight management. Usually via GP
• Be aware of comorbidities or predisposition to dental disease.
• Appropriate referral onto Secondary and Tertiary care.
• May have to provide emergency care prior to onward referral.
• Raise concerns with patient, parents or carers of vulnerable adults and children.

Obese patients may present significant medical, logistical and surgical challenges. Nevertheless the majority are healthy for dental tx

Question 16

dental team things to do prior to bariatric appointment

Answer 16

Ensure your venue has appropriate facilities for patient care.

This may involve telephoning the patient/referrer/carer prior to initial visit querying: Patient Weight or BMI, Mobility
- e.g. do they use a wheelchair? Manual or motorised?

Question 17

NAFLD

Answer 17

non alcoholic fatty liver disease

Question 18

things to consider for travel of bariatric pt

Answer 18

Is the patient taking private transport e.g car / taxi? Parking should be available as close to the venue as possible.

Ambulance transport - will only take patients to Hospitals

Question 19

accessibility consideration for bariatric pt

Answer 19

Waiting room with suitable high weight bearing armless chair. (right)

Adequate door widths

Toilet facilities accessible (wheelchair)

Is the practice accessible via lift or stairs (reinforced lift/stairs/walkway)?

Emergency Evacuation procedures (lift out of boundaries)

Under no circumstances should staff attempt to break the fall of an obese patient

Question 20

timing considerations for bariatric pts

Answer 20

May require longer appointment times due to reduced mobility

Extra weight around the face can obstruct the access to the mouth

Question 21

safety consideration for bariatric pts

Answer 21

Specialist equipment may mean patients need referral to specialist clinics or hospitals

• Wider cuff blood pressure monitors. (e.g. “thigh cuff”);
• Longer IM needles are needed.

May be unable to get patient rapidly into supine/recovery position or physically move patient.

Airway management may be more difficult.

Resuscitation – identification of landmarks for chest compressions may be difficult

Question 22

things to consider when bariatric pt in the chair

Answer 22

If the patient does not know their weight and is perceived to exceed 22 stone/140kg an accurate weight must be obtained through weighing the patient.
- Unfortunately most standard weighing scales only weigh up to 22 stone.

People who carry weight on their chest and upper body are at risk of hypoxaemia when lying flat.
- In extreme circumstances some obese patients may present with obesity hypoventilation syndrome, a result of chronic hypoventilation due to the excess weight preventing full expansion of the lungs.

Question 23

how to ask pt weight without intruding

Answer 23

Make inclusive in medical history – height and weight

- part of standard questions

Question 24

co - morbidities of obesity

Answer 24

Hypertension and Cerebrovascular accident (CVA)
- (Do they suffer from angina? At rest or on exertion?)

Diabetes

Sleep apnoea

Dyspnoea

Gastro oesophageal reflux disease (GORD)
- Especially after bariatric surgery

Osteoarthritis

Depression/anxiety
- Often directly related to embarrassment/shame due to their size

Liver and gallbladder disease

Skin conditions e.g. cellulitis and intertrigo

Question 25

intertigo

Answer 25

Inflammation within excessive body fold

Question 26

sleep apnoea

Answer 26

• breathing stops and starts in sleep
• gasping or choking
• May use a CPAP machine (Continuous positive airway pressure)

Question 27

dyspnoea

Answer 27

• Shortness of breath SOB

- Are they able to walk comfortably without getting breathless

Question 28

treatment of bariatric pt obstacles

Answer 28

Loss of anatomical landmarks is possible.
- There are access problems with large cheeks, tongue etc.

ID blocks may be difficult.
- Alternative techniques may need to be considered such as the Gow-Gates or intraligamentary techniques.

Consider use of a ‘Lax’ tongue retractor if a dental mirror is insufficient for soft tissue retraction (top; or lolly pop sticks retractors)

May have to be treated semi-supine or sitting upright
- Beware operator musculo-skeletal problems when working in a less than ideal position.

Intra-oral radiography can be more challenging due to increased soft tissues.
- OPT can be difficult or even impossible if the machine is unable to accommodate the patient’s size.

Long procedures can lead to acute leg oedema, cellulitis, Compartment Syndrome and pressure sores.

Coagulation abnormalities may occur (e.g. due to non-alcoholic fatty liver disease)
- Check bloods before extractions or potentially bleeding procedures

Excessive fat in the tissues may also affect pharmacological absorption of a drug

Question 29

compartment syndrome

Answer 29

painful, bleeding and swelling within enclosed muscles increasing pressure, restricts the blood flow and damages nerves/muscles

Question 30

dental implications of bariatric pt (4)

Answer 30

periodontitis

caries

wound healing

tooth wear

Question 31

periodontitis impact from bariatric patient

Answer 31

The relationship between obesity and periodontal disease has been acknowledged as associative but there is no evidence of a causal relationship.

Obesity does not appear to play a negative role in the treatment outcome of non-surgical periodontal therapy.

Diabetic pt - higher associated risk of periodontal disease. (linked to obesity)
- Be aware of the complexity of obesity and be able to discuss the importance of maintaining healthy body weight and performing good oral hygiene ne procedures.

Question 32

caries impact from bariatric pt

Answer 32

Bariatric patients may have a higher caries rate than general population as causations are interrelated (diet high in processed sugars).

Question 33

wound healing impact from bariatric pt

Answer 33

Extractions, Surgical Periodontal Treatment, Biopsies;

- Bariatric patients are more likely to have reduced immune function leading to delayed wound healing.

Question 34

tooth wear impact from bariatric patient

Answer 34

Erosive tooth wear is more likely - increased prevalence of GORD in bariatric persons.

Increased incidence of oesophageal reflux, in particular in those having gastric banding, causing acid erosion.

Question 35

how to treat Mr M

46 year old male from Glasgow.
- Has had toothache for the last few days keeping him awake at night.
- Not seen dentist in many years “never fit the last chair which was embarrassing” and led him to never go back for treatment.
“Teeth are a mess”

MH: Type 2 Diabetic, Asthmatic, NAFLD non-alcohol fatty liver disease

BMI of 37 (WHO obesity class II)

Occasionally mobilises in wheelchair when out

Answer 35

Full dental and medical histories

Dental examination in patients own wheelchair

Special Investigations: radiograph of painful tooth
- finds unrestorable subgingival caries and periapical pathology relating to lower right first permanent molar

Treatment:
- Do nothing – nope, in pain
- Extraction - Positioning of yourself and patient, do you feel confident in your IDB placement, should you take bloods for a coagulation screening? Review healing after?
- Extirpation – Get nerve out – inc time before extraction as pain relieved
Positioning of yourself and patient. Can you comfortably place rubber dam?

Referral onto Public Dental Service for bariatric chair for extraction – safer environment

Question 36

domiciliary care

Answer 36

Rarely the first line option.

Useful option when patients are too large and/or too anxious to leave their home.

A domiciliary visit may also be useful for initial assessment, then arranging further review in the clinic. Full risk assessment (as per any domiciliary visit) is essential.
- Obese individuals are twice as likely to be cared for in nursing homes

Question 37

domiciliary care options

Answer 37

Treatment is usually restricted to inexpensive, short procedures which carry little risk such as examinations.

The most common type of dental procedure carried out is prosthetics.
Or exam, dressings etc not extirpation

Question 38

categories of pt requiring domiciliary care (10)

Answer 38

Neurological and mental illness e.g. dementia, dental phobia

Intellectual impairment such as learning disability

Physical impairment due to conditions such as cerebral palsy and epilepsy

Homeless people in hostels

Severe cardiovascular disease e.g. stroke

Severe respiratory disease e.g. COPD Chronic Obstructive Pulmonary Disease

Hospital in patients

Older people

Bariatric patients

Palliative care patients

Question 39

emergency appointments for

Answer 39

emergency relief of pain treatment only, weighing up risks and benefits.

Question 40

emergency appointments considerations

Answer 40

Patient and staff health and safety should not be compromised.

If a patient is unsuitable for your dental chair consider treating in their own wheelchair or in a bariatric wheelchair.
- Future appointments should be arranged in clinic with suitable facilities

Question 41

bariatric care and learning disability

Answer 41

Between 2017 and 2018, obesity was found to be twice as common in patients with a learning disability aged 18–35 than those without.

Those with learning disabilities can experience weight gain, especially those living independently unless they have careful diet control

Thought to be multifactorial, with people with learning disabilities often having poorly balanced diets, more sedentary lifestyles and possible genetic predisposition to weight gain, such is the case in Prader-Willi syndrome or in Down syndrome.

Anti-psychotic medications, such as clozapine and olanzapine, predispose patients to weight gain

Question 42

anxiety in bariatric pts

Answer 42

study found obese women reported significantly more dental anxiety compared with “normal” weight women when using the Dental Fear Survey (DFS) questionnaire.

Question 43

inhalation sedation in bariatric pts

Answer 43

No specific contraindications however special care must be taken to ensure good safe airway management.

This may be the most appropriate form of sedation for these patients.

Question 44

intravenous sedation and bariatric pts

Answer 44

Obese adults are at risk of sleep apnoea - a contraindication to dental sedation in a primary care setting.

Bariatric adults are not suitable for conscious sedation in a standard dental clinic due to difficulty placing cannula.

Bariatric adults may have compromised airways which require specialist teams to manage in an emergency with the appropriate resuscitation equipment.

Question 45

general anaesthetic and bariatric pts

Answer 45

Obese patients are twice as likely to develop serious airway problems during a GA than the non-obese

Question 46

communication and bariatric pts

Answer 46

Explain any changes to treatment plan/venue as a result of their weight sensitively but honestly.

Patients may be quite resistant to being referred elsewhere - they may feel ashamed or upset.

They may have experienced discrimination in many services because of their size.

Highlight the importance of you and your patient’s safety and also the need for the best possible care in the best possible setting. Keep reasons technical and not personal.

Making too much of an issue regarding a patient’s weight may only serve to make them more embarrassed and anxious when attending the dentist.
- This may make them less likely to re-attend

Arrange onward referral as required and keep the patient informed

Question 47

examples of communication to use with bariatric pts that may be favoured

Answer 47

Larger patients may prefer to be referred to as ‘overweight’ rather than ‘obese’

“You are slightly above the weight limit of this chair, we have an alternative chair which we can use”

Question 48

bariatric surgery - positives

Answer 48

Results in greater improvement in weight loss outcomes, improved control of comorbidities and significant improvement in self-esteem

Question 49

bariatric surgery - negatives

Answer 49

e.g. nutritional deficiencies, “dumping” syndrome and eating disorders, such as anorexia, bulimia and compulsive eating.

Rapid gastric emptying – diahorrea, nausea, light headed/tired

Question 50

bariatric surgery correlations with oral problems e.g. (6)

Answer 50

periodontal disease,

increase in dental caries,

hyposalivation,

ulcers,

dentine sensitivity

halitosis.

Question 51

post bariatric surgery advice

Answer 51

Following surgery, patients are advised to divide food intake into 4-6 meals throughout the day, chewing slowly.
- Higher frequency and prolonged mealtimes
= increase risk of caries as sugary items are ingested.

At increased risk of dental erosion due to the common side effect of reflux and vomiting

Question 52

GDPs diet advice to patients (bariatric especially)

Answer 52

Ingestion of a healthy, balanced diet (reduction in the quantity and frequency of foods and beverages with added sugar, avoid eating at night);

Adequate oral hygiene.

Stimulate salivary flow to avoid dry mouth (increase water ingestion by taking a bottle with you and drinking small sips) +/- artificial saliva;

Increase the consumption of foods rich in fibre;

Chew gum without sugar, but only two month after surgery;

To avoid halitosis or coated tongue, brush the tongue or use a tongue scraper;

Take care to avoid tooth wear (diminish consumption of acidic foods, such as citrus fruit, vinegar and soft drinks);

Drink soft drinks or fruit juices through a straw to minimize contact with the teeth; in case of ingesting soft drinks, never brush right afterwards, but perform mouth rinsing with water;

Never brush the teeth after episodes of vomiting or reflux, if you are not at home, perform mouth rinsing with water or chew gum without sugar; if you are at home: perform mouth rinsing with sodium bicarbonate (one teaspoon in half a glass of water, to alkalinize the oral medium, and wait for half an hour before brushing your teeth).

Provide topical fluoride varnish and OHI as required

Question 53

malpractice bariatric dental care

Answer 53

“Oral jaw wiring (OJW) or maxilla-mandibular fixation (MMF) have been applied in an effort to control obesity

retainer-like device that makes obese patients take smaller bites, which is custom-made to fit the roof of the patient’s mouth
- Lack of space inside the mouth forces the patient to consume less quantities of food.

several dental journals warning dentists with different articles that use intraoral devices for the treatment of obesity may be considered outside the practice of dentistry and can be considered as malpractice.”