Special Care Dentistry Flashcards

Question

what is an emergency detention certificate?

Answer 1

An emergency detention certificate allows a person to be held in hospital for up to 72 hours while their condition is assessed.

Answer 2

A compulsory treatment order (CTO) allows for a person to be treated for their mental illness. The CTO will set out a number of conditions that you will need to comply with. These conditions will depend on whether you have to stay in hospital or are in the community.

Answer 3

When one or more of a person's senses is no longer normal A person does not have to have full loss of a sense to be sensory impaired

Answer 4

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

Answer 5

Cataract is clouding of the lens of the eye which prevents clear vision. Majority related to ageing process Occasionally children can be born with the condition Cataract may develop after eye injuries, inflammation, and some other eye diseases.

Answer 6

Age-related macular degeneration (AMD) is a condition affecting older people Involves the loss of the person's central field of vision. It occurs when the macular (or central) retina develops degenerative lesions. The macula, a tiny area within the retina at the back of the eye. The cells of the macula are photoreceptor cells, which means they’re sensitive to light and play a vital role in our ability to see details and colour The cells become damaged and scarred. It is thought that circulatory insufficiency, with reduction in the blood flow to the macular area, also plays a part. Several forms of AMD exist.

Answer 7

Causes severe sight loss in a matter of months can develop very rapidly, resulting in more sudden sight loss. Growth of new vessels under retina which then break and leak into the macula Occurs when unhealthy new blood vessels begin to grow under the macula and leak blood and fluid (this is why it’s called ‘wet’ macular degeneration), which then causes scarring to develop within the macula cells.

Answer 8

Bilateral condition 90% of cases Thought to have a hereditary element and myopia may be a predisposing factor. Gradual loss of central vision. Person becomes unable to recognise people because they cannot see their faces clearly, cannot see bus numbers etc. Layers of the macula become progressively thinner, causing it to function less effectively.

Answer 9

Bilateral condition 90% of cases Thought to have a hereditary element and myopia may be a predisposing factor. Gradual loss of central vision. Person becomes unable to recognise people because they cannot see their faces clearly, cannot see bus numbers etc. Layers of the macula become progressively thinner, causing it to function less effectively.

Answer 10

Primary open angle glaucoma (POAG) Angle closure glaucoma (ACG),

Answer 11

Slow and insidious onset Anterior chamber angle is open Caused by the drainage channels in the eye becoming gradually clogged over time.

Answer 12

Less common More acute Caused by the drainage in the eye becoming suddenly blocked, Can raise the pressure inside the eye very quickly

Answer 13

Diabetic retinopathy is composed of a characteristic group of lesions found in the retina of individuals having had diabetes mellitus for several years. The abnormalities that characterise diabetic retinopathy occur in predictable progression with minor variations in the order of their appearance. Diabetic retinopathy is considered to be the result of vascular changes in the retinal circulation. In the early stages vascular occlusion and dilations occur. It progresses into a proliferative retinopathy with the growth of new blood vessels. Macular oedema (the thickening of the central part of the retina) can significantly decrease visual acuity.

Answer 14

Over time, continuously high blood sugar levels can cause the blood vessels to become blocked or to leak.

Answer 15

background retinopathy – tiny bulges develop in the blood vessels, which may bleed slightly but this doesn't usually affect vision pre-proliferative retinopathy – more severe and widespread changes affect the blood vessels, including more significant bleeding into the eye proliferative retinopathy – scar tissue and new blood vessels, which are weak and bleed easily, develop on the retina. This can result in some loss of vision

Answer 16

Duration of diabetes Level of glycemia Presence of high blood pressure Dependence on insulin Pregnancy Levels of selected serum lipids Nutritional Genetic factors

Answer 17

Hemianopia is blindness in one half of the visual field. This loss can be caused by a variety of medical conditions – stroke being the most common Hemianopia is a functional defect which can affect the right or left side. Stroke patients with weakness of, for example, the right arm and leg have right sided poor vision. Sight loss can be upper, lower, left or right.

Answer 18

Always identify yourself even in known surroundings Always use names to identify people - especially in a group situation Keep the visually impaired person informed of people moving around and/or leaving the room Tell them what your doing before you do it – putting the chair back / LA / slow speed

Answer 19

A person who is not able to hear as well as someone with normal hearing – hearing thresholds of 25 dB or better in both ears – is said to have hearing loss. Hearing loss may be mild, moderate, severe, or profound. It can affect one ear or both ears, and leads to difficulty in hearing conversational speech or loud sounds.

Answer 20

Mild 20 – 40 decibels Moderate 41 – 70 decibels Severe 71 – 95 decibels Profound 95+ decibels

Answer 21

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

Answer 22

Underlying health problems e.g. hypothyroidism in Down’s syndrome and eating issues such as Prader-Willi syndrome A lack of energy Difficulty with chewing or swallowing food or its taste or texture 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 or have pain on movement (e.g. in cerebral palsy, rheumatoid arthritis Lifestyle Factors: A lack of healthy food choices; accessible environments that enable exercise; resources and appropriate social support systems

Answer 23

Loss of anatomical landmarks is possible. Access issues 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

Answer 24

May have to be treated semi-supine or sitting upright – practitioners need to be careful with their posture.

Answer 25

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.

Answer 26

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

Answer 27

pharmacological absorption of a drug

Answer 28

Caries Wound Healing: Extractions, Surgical Periodontal Treatment, Biopsies Bariatric patients are more likely to have reduced immune function leading to delayed wound healing. Tooth-wear: 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.

Answer 29

inhalation sedation

Answer 30

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

Answer 31

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

Answer 32

Negative consequences e.g. nutritional deficiencies, “dumping” syndrome and eating disorders, such as anorexia, bulimia and compulsive eating. Correlation with oral problems, such as periodontal disease, increase in dental caries, hyposalivation, ulcers, dentine sensitivity and halitosis. Following surgery patients are advised to divide food intake into 4-6 meals throughout the day, chewing slowly. Higher frequency and prolonged meal times = 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

Answer 33

- 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

Answer 34

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

Answer 35

Physical access is a barrier to care. - disabled parking - width of spaces - kerb/pavement - path into building - tiles which could be broken/slippery when wet? - ground level access or if stairs: - ramp access - grab rail - lift

Answer 36

Physical access is a barrier to care. - height of reception desk - adequate space for wheel in waiting area - door width - obstacles - keep corridor clear - level threshold - door opening position and door handles - toilet that is accessible to those in a wheelchair - training for reception staff - first point of contact

Answer 37

No matter what our personal beliefs maybe, Dentistry is a profession where the moral and ethical principles of equality and diversity must be embraced to ensure access and fair treatment for all people. We have a responsibility to enable people to receive the highest quality of care we are capable of. Just because someone lives with impairment or disability does not mean they should be subject to inequality, inequity, discrimination or prejudice.

Answer 38

Legal framework: The Equality Act 2010: Legal framework to protect those from discrimination for reason of: disability, race, sex, sexual orientation, religion, age, pregnancy, transsexuality Brings together multiple different Acts including The Disability Discrimination Act 1995 to make the law simpler and clearer. For disability the new legislation improves protection by: - Concept of reasonable adjustment – changes how things are done, changes to buildings, provision of aids - Making it easier for someone to show that they have difficulty carrying out their day-to-day activities – ability to access financial support - Protecting from indirect discrimination - Positive action - when something is done specifically to help someone who has a protected characteristic – e.g., encouraging or training people to apply for jobs or take part in an activity in which people with that characteristic are underrepresented. - Employers can no longer ask direct questions about disability (unless there is good reason)

Answer 39

A Reasonable Adjustment is any step which can be reasonably taken to prevent any provision, criterion or practice, or any physical feature of its premises, from putting a disabled person at a disadvantage in comparison with a non-disabled person.  Factors to be weighed up in determining reasonableness are:  how effective the adjustment is in preventing the disadvantage  how practical it is  the cost of making the adjustment  the potential disruption caused  the time, effort and resources involved  number of resources already spent on making other adjustments  the availability of financial or other help. Cost can be a major factor when deciding whether an adjustment is reasonable. The majority of adjustments are relatively inexpensive if not free

Answer 40

- Providing a ramp in addition to the stairs up into the practice

Answer 41

- A lift in a practice which is in an old tenement building

Answer 42

If you in your practice unable to allow a patient to access your surgery you have a responsibility to facilitate care for them at a place which can. e) Mrs Johnson is unable to transfer to the dental chair by herself. What feasible options are available to aid her transfer? Discuss their benefits and weaknesses.

Answer 43

1) Hoist positives: - Can be used for non-weight bearing individuals - Allows transfer to dental chair, safest management environment limitations: - Additional training required - Additional equipment 2) Banana Board positives: - Self transfer limitations: - Generally, Requires leg break chair 3) Reclining Wheelchair positives: - No need to transfer limitations: - Dentist access challenging - Management of medical emergencies - Expensive equipment 4) Turn Table positives: - Promotes involvement of patient limitations: - Additional equipment 5) Wheelchair recliner positives: - No need to transfer - No cost to dentist - Access in GDP limitations: - Dentist access challenging - Management of medical emergencies 6) Stand Aid positives: - Promotes involvement of patient limitations: - Must be able to weight bear - Specialist equipment

Answer 44

Follow the same principles as for any other patient. However, perhaps more time is required find out about her medical condition. Asking questions during the history taking process is essential to allow you to build up picture of the patient.

Answer 45

To obtain the necessary details to inform your clinical assessment and management plan

Answer 46

Further questioning for this lady may include: C/O and HPC : more detailed pain history – SOCRATES pain assessment ? MH: stability of her condition, medications, prognosis SH: how does she travel to the clinic, timings of treatment (not early appointments – a best time of the day?) Dry mouth – this lady has a diagnosis of Rheumatoid arthritis. Whilst there are multiple causes for dry mouth, the risk of Sjogren’s is particularly pertinent she has an already existing autoimmune condition. Consider asking about: Symptoms: Occular and oral symptoms Signs: Tendency of the mucosa to stick to a dental mirror or tongue spatula; food residues within the oral cavity; frothiness of saliva, particularly in the lower sulcular reflection; and the absence of frank salivation from major gland duct orifices. The tongue may develop a characteristic appearance: a lobulated, red surface with partial or complete depapillation. Salivary gland enlargement American-European Consensus Group Criteria. Revised international classification criteria for Sjögren’s syndrome (SEE IT ON RHEUMATOLOGY GUIDANCE SHEET)

Answer 47

Rheumatoid arthritis, or RA, is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body. RA mainly attacks the joints, usually many joints at once. RA commonly affects joints in the hands, wrists, and knees. In a joint with RA, the lining of the joint becomes inflamed, causing damage to joint tissue. This tissue damage can cause long-lasting or chronic pain, unsteadiness (lack of balance), and deformity (misshapenness). RA can also affect other tissues throughout the body and cause problems in organs such as the lungs, heart, and eyes.

Answer 48

With RA, there are times when symptoms get worse, known as flares, and times when symptoms get better, known as remission. Signs and symptoms of RA include:  Pain or aching in more than one joint  Stiffness in more than one joint  Tenderness and swelling in more than one joint  The same symptoms on both sides of the body (such as in both hands and both knees)  Weight loss  Fever  Fatigue or tiredness  Weakness

Answer 49

RA is the result of an immune response in which the body’s immune system attacks its own healthy cells. The specific causes of RA are unknown, but some factors can increase the risk of developing the disease.

Answer 50

Characteristics that increase risk  Age. RA can begin at any age, but the likelihood increases with age. The onset of RA is highest among adults in their sixties.  Sex. New cases of RA are typically two-to-three times higher in women than men.  Genetics/inherited traits. People born with specific genes are more likely to develop RA. These genes, called HLA (human leukocyte antigen) class II genotypes, can also make your arthritis worse. The risk of RA may be highest when people with these genes are exposed to environmental factors like smoking or when a person is obese.  Smoking. Multiple studies show that cigarette smoking increases a person’s risk of developing RA and can make the disease worse.  History of live births. Women who have never given birth may be at greater risk of developing RA.  Early Life Exposures. Some early life exposures may increase risk of developing RA in adulthood. For example, one study found that children whose mothers smoked had double the risk of developing RA as adults. Children of lower income parents are at increased risk of developing RA as adults.  Obesity. Being obese can increase the risk of developing RA. Studies examining the role of obesity also found that the more overweight a person was, the higher his or her risk of developing RA became.

Answer 51

RA is diagnosed by reviewing symptoms, conducting a physical examination, and doing X-rays and lab tests. It’s best to diagnose RA early—within 6 months of the onset of symptoms—so that people with the disease can begin treatment to slow or stop disease progression (for example, damage to joints). Diagnosis and effective treatments, particularly treatment to suppress or control inflammation, can help reduce the damaging effects of RA.

Answer 52

RA can be effectively treated and managed with medication(s) and self-management strategies. Treatment for RA usually includes the use of medications that slow disease and prevent joint deformity, called disease-modifying antirheumatic drugs (DMARDs); biological response modifiers (biologicals) are medications that are an effective second-line treatment. In addition to medications, people can manage their RA with self-management strategies proven to reduce pain and disability, allowing them to pursue the activities important to them. People with RA can relieve pain and improve joint function by learning to use five simple and effective arthritis management strategies.

Answer 53

Rheumatoid arthritis (RA) has many physical and social consequences and can lower quality of life. It can cause pain, disability, and premature death.  Premature heart disease. People with RA are also at a higher risk for developing other chronic diseases such as heart disease and diabetes. To prevent people with RA from developing heart disease, treatment of RA also focuses on reducing heart disease risk factors. For example, doctors will advise patients with RA to stop smoking and lose weight.  Obesity. People with RA who are obese have an increased risk of developing heart disease risk factors such as high blood pressure and high cholesterol. Being obese also increases risk of developing chronic conditions such as heart disease and diabetes. Finally, people with RA who are obese experience fewer benefits from their medical treatment compared with those with RA who are not obese.  Employment. RA can make work difficult. Adults with RA are less likely to be employed than those who do not have RA. As the disease gets worse, many people with RA find they cannot do as much as they used to. Work loss among people with RA is highest among people whose jobs are physically demanding. Work loss is lower among those in jobs with few physical demands, or in jobs where they have influence over the job pace and activities.

Answer 54

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones). Osteoporosis is a “silent” disease because you typically do not have symptoms, and you may not even know you have the disease until you break a bone. Osteoporosis is the major cause of fractures in postmenopausal women and in older men. Fractures can occur in any bone but happen most often in bones of the hip, vertebrae in the spine, and wrist.

Answer 55

However, you can take steps to help prevent the disease and fractures by:  Staying physically active by participating in weight-bearing exercises such as walking.  Drinking alcohol in moderation.  Quitting smoking, or not starting if you don’t smoke.  Taking your medications, if prescribed, which can help prevent fractures in people who have osteoporosis.  Eating a nutritious diet rich in calcium and vitamin D to help maintain good bone health.

Answer 56

Osteoporosis affects women and men of all races and ethnic groups. Osteoporosis can occur at any age, although the risk for developing the disease increases as you get older. For many women, the disease begins to develop a year or two before menopause. Other factors to consider include:  Osteoporosis is most common in non-Hispanic white women and Asian women.  African American and Hispanic women have a lower risk of developing osteoporosis, but they are still at significant risk.  Among men, osteoporosis is more common in non-Hispanic whites. Certain medications, such as some cancer medications and glucocorticoid steroids, may increase the risk of developing osteoporosis. Because more women get osteoporosis than men, many men think they are not at risk for the disease. However, both older men and women from all backgrounds are at risk for osteoporosis. Some children and teens develop a rare form of idiopathic juvenile osteoporosis. Doctors do not know the cause; however, most children recover without treatment.

Answer 57

Osteoporosis occurs when too much bone mass is lost and changes occur in the structure of bone tissue. Certain risk factors may lead to the development of osteoporosis or can increase the likelihood that you will develop the disease. Many people with osteoporosis have several risk factors, but others who develop osteoporosis may not have any specific risk factors. There are some risk factors that you cannot change, and others that you may be able to change. However, by understanding these factors, you may be able to prevent the disease and fractures.

Answer 58

Sex. Your chances of developing osteoporosis are greater if you are a woman. Women have lower peak bone mass and smaller bones than men. However, men are still at risk, especially after the age of 70. Age. As you age, bone loss happens more quickly, and new bone growth is slower. Over time, your bones can weaken and your risk for osteoporosis increases. Body size. Slender, thin-boned women and men are at greater risk to develop osteoporosis because they have less bone to lose compared to larger boned women and men. Race. White and Asian women are at highest risk. African American and Mexican American women have a lower risk. White men are at higher risk than African American and Mexican American men. Family history. Researchers are finding that your risk for osteoporosis and fractures may increase if one of your parents has a history of osteoporosis or hip fracture. Changes to hormones. Low levels of certain hormones can increase your chances of developing osteoporosis Low oestrogen levels in women after menopause. Low levels of oestrogen from the abnormal absence of menstrual periods in premenopausal women due to hormone disorders or extreme levels of physical activity. Low levels of testosterone in men. Men with conditions that cause low testosterone are at risk for osteoporosis. However, the gradual decrease of testosterone with aging is probably not a major reason for loss of bone. Diet. Beginning in childhood and into old age, a diet low in calcium and vitamin D can increase your risk for osteoporosis and fractures. Excessive dieting or poor protein intake may increase your risk for bone loss and osteoporosis. Other medical conditions. Some medical conditions that you may be able to treat or manage can increase the risk of osteoporosis, such as other endocrine and hormonal diseases, gastrointestinal diseases, rheumatoid arthritis, certain types of cancer, HIV/AIDS, and anorexia nervosa. Medications. Long-term use of certain medications may make you more likely to develop bone loss and osteoporosis, such as: Glucocorticoids and adrenocorticotropic hormone, which treat various conditions, such as asthma and rheumatoid arthritis. Antiepileptic medicines, which treat seizures and other neurological disorders. Cancer medications, which use hormones to treat breast and prostate cancer. Proton pump inhibitors, which lower stomach acid. Selective serotonin reuptake inhibitors, which treat depression and anxiety. Thiazolidinediones, which treat type II diabetes. Lifestyle. A healthy lifestyle can be important for keeping bones strong. Factors that contribute to bone loss include: Low levels of physical activity and prolonged periods of inactivity can contribute to an increased rate of bone loss. They also leave you in poor physical condition, which can increase your risk of falling and breaking a bone. Chronic heavy drinking of alcohol is a significant risk factor for osteoporosis. Studies indicate that smoking is a risk factor for osteoporosis and fracture. Researchers are still studying if the impact

Answer 59

The goals for treating osteoporosis are to slow or stop bone loss and to prevent fractures. Your health care provider may recommend:  Proper nutrition.  Lifestyle changes.  Exercise.  Fall prevention to help prevent fractures.  Medications.

Answer 60

An important part of treating osteoporosis is eating a healthy, balanced diet, which includes: Plenty of fruits and vegetables. An appropriate number of calories for your age, height, and weight. Your health care provider or doctor can help you determine the number of calories you need each day to maintain a healthy weight. Foods and liquids that include calcium, vitamin D, and protein. These helps minimize bone loss and maintain overall health. However, it’s important to eat a diet rich in all nutrients to help protect and maintain bone health. Calcium and Vitamin D Calcium and vitamin D are important nutrients for preventing osteoporosis and helping bones reach peak bone mass. If you do not take in enough calcium, the body takes it from the bones, which can lead to bone loss. This can make bones weak and thin, leading to osteoporosis.

Answer 61

In addition to a healthy diet, a healthy lifestyle is important for optimizing bone health. You should: Avoid second hand smoke, and if you smoke, quit. Drink alcohol in moderation, no more than one drink a day for women and no more than two drinks a day for men. Visit your doctor for regular check-ups and ask about any factors that may affect your bone health or increase your chance of falling, such as medications or other medical conditions.

Answer 62

Exercise is an important part of an osteoporosis treatment program. Research shows that the best physical activities for bone health include strength training or resistance training. Because bone is living tissue, during childhood and adulthood, exercise can make bones stronger. However, for older adults, exercise no longer increases bone mass. Instead, regular exercise can help older adults: Build muscle mass and strength and improve coordination and balance. This can help lower your chance of falling. Improve daily function and delay loss of independence. Although exercise is beneficial for people with osteoporosis, it should not put any sudden or excessive strain on your bones. If you have osteoporosis, you should avoid high-impact exercise

Answer 63

Bisphosphonates. Several bisphosphonates are approved to help preserve bone density and strength and to treat osteoporosis. This type of drug works by slowing down bone loss, which can lower the chance of fractures. Calcitonin. This medication is made from a hormone from the thyroid gland and is approved for the treatment of osteoporosis in postmenopausal women who cannot take or tolerate other medications for osteoporosis. Oestrogen agonist/antagonist. An oestrogen agonist/antagonist, also known as a selective oestrogen receptor modulator (SERM), and tissue-selective oestrogen complex (TSEC), are both approved to treat and prevent osteoporosis in postmenopausal women. They are not oestrogen, but they have oestrogen-like effects on some tissues and oestrogen-blocking effects on other tissues. This action helps improve bone density, lowering the risk for some fractures. Oestrogen and hormone therapy. Oestrogen and combined oestrogen and progestin (hormone therapy) are approved to prevent osteoporosis and fractures in postmenopausal women. Because of potential side effects, researchers recommend that women use hormone therapy at the lowest dose, and for the shortest time, and if other medications are not helping. It is important to carefully consider the risks and benefits of oestrogen and hormone therapy for the treatment of osteoporosis. Parathyroid hormone (PTH) analog and parathyroid hormone related protein (PTHrP) analog. PTH is a form of human parathyroid hormone that increases bone mass and is approved for postmenopausal women and men with osteoporosis who are at elevated risk for fracture. PTHrP is a medication that is also a form of parathyroid hormone. It is an injection and is usually prescribed for postmenopausal women who have severe osteoporosis and a history of multiple fractures. RANK ligand (RANKL) inhibitor. This is an inhibitor that helps slow down bone loss and is approved to treat osteoporosis in: Postmenopausal women or men with osteoporosis who are at elevated risk for fracture. Men who have bone loss and are being treated for prostate cancer with medications that cause bone loss. Women who have bone loss and are being treated for breast cancer with medications that cause bone loss. Men and women who do not respond to other types of osteoporosis treatment. Sclerostin inhibitor. This is a medication that treats severe osteoporosis by blocking the effect of a protein, and helps the body increase new bone formation as well as slows down bone loss.

Answer 64

Methotrexate This is one of the non-biologic disease-modifying anti-rheumatic drugs (DMARDs). Methotrexate inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines. It has anti-inflammatory and immunosuppressive effects. This person will have regular routine bloodwork undertaken. This will allow us to evaluate their response to the drug and determine safety to manage the patient. You may wish these to be updated prior to undertaking dental treatment. DMARD’s are not routinely stopped for dental treatment. Antibiotic prophylaxis is not routine, but maybe considered on a case by case basis for the most immunosuppressed of individuals. For BIOLOGICAL DMARDs it is valuable to liaise with the prescribing clinician, as timing of treatment is normally important to avoid interruption to drug regimens and to maximise the immune status of the patient. Of note, this person should also be prescribed folic acid. * Diclofenac Non-steroidal anti-inflammatory medicine * Paracetamol Analgesic and anti-pyrexic * Prednisolone – Short course when there is a flare of her symptoms, last flare 3 months ago Prednisolone exerts predominantly glucocorticoid effects with minimal mineralocorticoid effects. There has been a long and very controversial clinical and academic discussion surrounding the longterm use of glucocorticoid in patients and the need for additional steroid cover. New guidance is currently being written; however, these are likely to support steroid cover for individuals who have taken 5mg prednisolone or equivalent for longer than 4 weeks and are thus at risk of HPA axis suppression (Sagar 2020) and adrenal crisis if physiologically stressed for instance during acute illness, surgery or other invasive procedures. It is likely that the guidance will suggest doubling the dose of steroid for this group ( up to a dose of 10-15mg of prednisolone, although this is currently uncertain). For those with primary adrenal insufficiency, steroid cover should always be provided. * Calichew Calcium and vitamin D3 tablet

Answer 65

1. Dry mouth 2. Chronic Periapical Periodontitis: 27,35, 37,45, and 46. 3. Caries:17,16, 12,26,27,37,46,47,48 4. Chronic generalized mild periodontitis – pocket charting required to confirm Additional Findings: Retained roots: 35 and 46

Answer 66

- Medication related - Disease – Sjogren’s Syndrome maybe worth exploring in this lady, or diabetes - Dehydration

Answer 67

Dougall et al suggest that we consider access in 4 ways:  Access to the building Previously discussed  Access to the dental surgery Previously discussed  Access to the dental chair Previously discussed  Access to the mouth Rheumatoid Disease: Effects on TMJ – level of opening. Use of props? Role for sedation if muscular element?  Access to services: Appointment times, location and length. Transport. Prevention: Mrs Johnsons oral hygiene is obviously very poor. Plaque is a risk factor for multiple oral diseases. Mrs Johnson’s rheumatoid arthritis affects her manual dexterity. She struggles to brush her teeth because she cannot hold a toothbrush. Consider the volume and type of dental treatment – conducting 4 quadrant dentistry requiring multiple extractions, restorations, in a patient with limited mouth opening for a brief period of time may not be appropriate. Treatment will have to planned considering access elements and drug regimens: (long term steroids, immune status, new biological drugs) Long term : Stability of medical condition and dental disease rate If Sjogrens consider the complications:  Tooth demineralization and caries  Gingival changes  Difficulty with chewing  Impairment of denture use  Swallowing difficulties  Oral malodour  Altered taste  Mucosal dryness and sensitivity  Oral infections (candidiasis and bacterial sialadenitis)  Malignant change - B Cell Lymphoma risk

Answer 68

Acute management: Manage pain and swelling Stabilisation Phase: 1) Enhanced Prevention - OHI, Dietary Advice, Fluoride, Saliva Replacement/ Stimulation 2) PMPR if indicated on Pocket Charting 3) Attempt restoration of 17,16,12,26,48 4) Attempt Endodontics on 37 having assessed restorability(unlikely) – also consider previous disease experience, motivation, ability to co-operate and long term dental and general systemic prognosis 5) XLA 27, 28?, 35RR,45,46,47 6) Re-evaluate Restorative Phase: 7) Consider provision of restoration of spaces and 37 if successful RCT cuspal coverage 8) Maintenance care 3 monthly review as high caries risk? Give some consideration to her ability to cooperate with treatment either for reasons of anxiety, medical, social and behavioural reasons.

Answer 69

Provision of oral hygiene instruction Role of fluoride – Toothpaste, Varnish, Mouthwash is controversial

Answer 70

Discuss modes to make this easier to overcome physical disability: - Electric toothbrush - Collis curve toothbrush - Foam handles - Putty handles - Ball handles - Suction brush to stick to wall to clean dentures

Answer 71

Diagnosis: Pseudomembranous Candidosis Candidosis affecting the mouth generally occurs in those with predisposing factors. As oral health physicians we have a role to acknowledge and facilitate the further care of a person with underlying local or systemic factors. Whilst candidosis is a diagnostic we must always investigate the causative factors to ensure they are appropriately addressed.

Answer 72

Local factors - antibiotic use - dentures - local corticosteroid use - xerostomia * drug induced *radiotherapy induced General factors - drugs - extremes of age - endocrine * cushing syndrome *diabetes - immunodeficency *hereditary *acquired - nutritional deficencies *Fe - smoking Given the most recent HbA1c is 11.7mmol/l this this likey to be a predisposing factor, in addition to the fact this gentleman has an maxillary denture, which is ill-fitting and he performs oral hygiene and denture hygiene once daily.

Answer 73

Caries: 17,13,24,25,27, 37,36,35,45,46 and 47 - This gentleman has a high and frequent intake of cariogenic foodstuffs - He performs oral hygiene once daily - He may have a dry mouth as a result of his medications, this maybe worsened by the role of caffeine present in tea and coffee which is acknowledged as a diuretic. The significance of this role is dependent upon a number of other factors but may worsen the situation if consumed in excess Periapcial Periodontitis: 37 Generalised Chronic Periodontitis - Stage II -Grade B -Currently Unstable – Modified by Smoking tobacco and sub-optimally controlled diabetes - This gentleman presents with a number of risk factors for periodontal disease including - Smoking - Diabetes - particularly those with poor control - Dry mouth - loss of protective features of saliva

Answer 74

Atrial Fibrillation(AF) happens when the electrical impulses in the atria of the heart fire irregularly chaotically when they should be steady and regular, causing them to quiver or twitch (fibrillation). Symptoms include feeling an irregular and sometimes fast, heartbeat or pulse. Some people say it feels like their heart is fluttering or racing (known as palpitations). Atrial fibrillation might come and go (paroxysmal atrial fibrillation), but sometimes it doesn’t go away at all. It’s not life-threatening, but it’s considered serious because it could create blood clots in the heart that may lead to a stroke.

Answer 75

Diabetes is a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces. Insulin is a hormone made by the pancreas, that acts like a key to let glucose from the food we eat pass from the blood stream into the cells in the body to produce energy. All carbohydrate foods are broken down into glucose in the blood. Insulin helps glucose get into the cells. Not being able to produce insulin or use it effectively leads to raised glucose levels in the blood (known as hyperglycaemia). Over the long-term high glucose levels are associated with damage to the body and failure of various organs and tissues.

Answer 76

There are three main types of diabetes – type 1, type 2 and gestational. Type 1 diabetes can develop at any age, but occurs most frequently in children and adolescents. When you have type 1 diabetes, your body produces very little or no insulin, which means that you need daily insulin injections to maintain blood glucose levels under control. Learn more. Type 2 diabetes is more common in adults and accounts for around 90% of all diabetes cases. When you have type 2 diabetes, your body does not make good use of the insulin that it produces. The cornerstone of type 2 diabetes treatment is healthy lifestyle, including increased physical activity and healthy diet. However, over time most people with type 2 diabetes will require oral drugs and/or insulin to keep their blood glucose levels under control - Risk of hypoglycaemic episode – medical emergency - Increases prevalence, progression and severity of periodontal disease - Xerostomia - Oral Dysesthesia (Burning Mouth Syndrome) - Impaired wound healing - Increased risk of infections and severity, including candidosis - Parotid Gland Enlargement

Answer 77

High blood pressure is medically known as hypertension. It means your blood pressure is consistently too high and means that your heart has to work harder to pump blood around your body. High blood pressure is serious. If you ignore it, it can lead to heart and circulatory diseases like heart attack or stroke. It can also cause kidney failure, heart failure, problems with your sight and vascular dementia. Although your arteries are stretchy to cope with your blood pressure going up and down, if you have high blood pressure, your arteries lose their stretchiness and become stiff or narrow. The narrowing makes it easier for fatty material (atheroma) to clog them up. If the arteries that carry blood to your heart get damaged and clogged, it can lead to a heart attack. If this happens in the arteries that carry blood to your brain it can lead to a stroke. There isn’t always an explanation for the cause of high blood pressure, but most people develop high blood pressure because of their diet, lifestyle or medical condition. Sometimes high blood pressure runs in families and can also worsen with age. People living in deprived areas are at higher risk of having high blood pressure, and it is also more common if you are of black African or black Caribbean descent. Even in these cases, you may still be able to improve your blood pressure by changing your diet and being active. These can all increase your risk of getting high blood pressure:  Drinking too much alcohol  Smoking  Being overweight  Not doing enough exercise  Eating too much salt secondary hypertension. For example, an abnormal production of hormones from the adrenal glands can lead to high blood pressure. If your doctor gives you treatment for the hormonal condition, your blood pressure should then return to normal. Other causes of secondary hypertension include: kidney disease diabetes, and some medicines, such as oral contraceptives and some over the counter and herbal medicines.

Answer 78

Warfarin Mr Fraser is currently prescribed the medication warfarin but is scheduled to start a new drug called Apixaban This gentleman has been prescribed an anticoagulant and will be starting one of the new anticoagulant drugs. This will need to be considered in the planning and provision of dental treatment. The oral anticoagulants warfarin sodium, acenocoumarol and phenindione, antagonise the effects of vitamin K, and take at least 48 to 72 hours for the anticoagulant effect to develop fully; warfarin sodium is the drug of choice. If an immediate effect is required, unfractionated or low molecular weight heparin must be given concomitantly. Direct-acting oral anticoagulants (DOACs) include apixaban, dabigatran etexilate, edoxaban, and rivaroxaban. Dabigatran etexilate is a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation. Apixaban, edoxaban, and rivaroxaban are reversible inhibitors of activated factor X (factor Xa) which prevents thrombin generation and thrombus development.

Answer 79

HMG CoA reductase inhibitors and are used to treat hypercholesterolaemia.

Answer 80

This medication is one of the loop diuretics. It is used in combination with other hypertensive medications to control resistant hypertension. The loop diuretics can exacerbate diabetes however hyperglycaemia this is less than the thiazide diuretics

Answer 81

This a beta blocker. When considered in this context for its use in the management of hypertension it gives us an indication that this gentleman is not receiving a first line treatment. This should encourage us to consider the relevance of hypertension to our delivery of dental care. Insulin – The prescription of this medication indicates that this gentleman is now dependent upon replacement of insulin

Answer 82

Metformin hydrochloride has an anti-hyperglycaemic effect, Metformin hydrochloride is recommended as the first choice for initial treatment for all patients, due to its positive effect on weight loss, reduced risk of hypoglycaemic events and the additional long-term cardiovascular benefits associated with its use. Metformin can reduce Vit B12 levels, resulting in B12 decifiency anaemia

Answer 83

Reversibly inhibits sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.

Answer 84

The sulfonylureas act mainly by augmenting insulin secretion and consequently are effective only when some residual pancreatic beta-cell activity is present; during long-term administration they also have an extra pancreatic action. Metformin, Dapaglifloin and Sulfonylurea represents a triple therapy in the management of diabetes. It suggests that this gentleman has had challenges in achieving control of his condition which is also evident in the HbA1C.

Answer 85

Make a proposed treatment plan for this patient: 1. Establish a preventative regieme - OHI - Dietary Advice Stabilisation: 2. PMPR - NST 3. Attempt restoration of : 17,25,27,32,33,34,45 and 47 4. Extraction of 13,36,37,38 and 46 5. Immediate removable partial denture 6. Re-evaluate 7. Restorative Phase @ 6 months consider CoCr RPD Continue supportive periodontal care

Answer 86

During your medical history taking you should have noted that this person has a complex medical history. There are a number of issues which have been raised which you are required to find more information about. Diabetes – level of control Hypertension – level of control Medications – warfarin Prior to providing any dental treatment it would be valuable to understand what this gentleman’s bleeding risk is. This can be established through a special investigation. In particular the INR is of relevance. This will allow us to assess this gentleman’s bleeding risk and warfarin control. It is possible to provide some treatment for Mr Fraser today. You could provide him with the initial preventative messages that are essential to the long term maintenance of oral health.

Answer 87

We have made a diagnosis of pseudomembranous candiosis. Firstly we must assess the potential reasoning for the presence of this disease process. We must assess the potential risk factors and reasons for its presence. There are a several systemic or local factors which contribute to the risk of an oral fungal infection For this person, it is important to consider their diabetic control and the potential implications of the medications. He may also present with anaemia which could be a contributing factor to the presentation of this infection Additionally, we are aware that he is missing number of teeth and therefore is likely to wear a removable prosthesis. This can be a local factor which contributes to an oral candidosis. Management: The initial measures to manage this infection is to consider the nature of the disease. Candida exist in a biofilm. Therefore initially we should observe the principles of biofilm management and consider mechanical disruption. Additonally, it should be noted that there is an increase in the resistance profile of candida species to drug therapies. We should encourage the gentleman to: 1. Use a toothbrush or some gauze to clean the palate. This could be supplemented with the short term use of Corsodyl mouthwash or gel 2. Denture hygiene should be observed 3. The patient should be encouraged to remove the denture at night 4. Candidal species have the ability to penetrate the acrylic of dentures, therefore appropriate cleaning or even potentially a new denture may be required 5. It should be reinforced that underlying causes should be consider and investigated If first line management fails, the use of medications should be considered. Whenever considering the prescribing of medications we must evaluate the risk of interactions and consider the patients systemic health. It would be appropriate to start with a local agent in the management of pseudomembranous candidosis. a) Miconazole – This drug is contraindicated in patients taking warfarin as it potentiates the anticoagulant effect It is also contraincated for patient prescribed a statin as there is a possible increased risk of myopathy b) Nystatin This medication is safe to use in patients prescribed warfarin The use of systemic agents in the management of oral candidiasis should be considered as a final option for the majority or individuals

Answer 88

Yes, as a result of this individual taking the medication Warfarin it is important to ensure you have an INR. You may wish to request

Answer 89

An INR is a type of blood test and it is particularly useful for monitoring individual taking the medication warfarin. The INR is a ratio. It is calculated by taking the prothrombin time (PT) of the patient and dividing it by a reference PT plasm value which has been corrected for the thromboplastin used in the test. INR = PT / Reference PT Plasma The value of a normal healthy individual should be 1. For patient described Warfarin, there are target ranges in which the patient’s INR should sit. INR 2.5 for: treatment of deep-vein thrombosis or pulmonary embolism (including those associated with antiphospholipid syndrome or for recurrence in patients no longer receiving warfarin sodium) atrial fibrillation cardioversion—target INR should be achieved at least 3 weeks before cardioversion and anticoagulation should continue for at least 4 weeks after the procedure (higher target values, such as an INR of 3, can be used for up to 4 weeks before the procedure to avoid cancellations due to low INR) dilated cardiomyopathy mitral stenosis or regurgitation in patients with either atrial fibrillation, a history of systemic embolism, a left atrial thrombus, or an enlarged left atrium bioprosthetic heart valves in the mitral position (treat for 3 months), or in patients with a history of systemic embolism (treat for at least 3 months), or with a left atrial thrombus at surgery (treat until clot resolves), or with other risk factors (e.g. atrial fibrillation or a low ventricular ejection fraction) acute arterial embolism requiring embolectomy (consider long-term treatment) myocardial infarction INR 3.5 for: recurrent deep-vein thrombosis or pulmonary embolism in patients currently receiving anticoagulation and with an INR above 2; Mechanical prosthetic heart valves: the recommended target INR depends on the type and location of the valve, and patient-related risk factors consider increasing the INR target or adding an antiplatelet drug, if an embolic event occurs whilst anticoagulated at the target INR.

Answer 90

We have not previously met this individual. If we had access to his INR results we could assess his level of control of his medication and the risk of undertaking any procedures. We can access this information through digital medical records or in more traditional setting in a little yellow book which the patient may carry. If we take everything into account about this gentleman including his poor control of diabetes, his multiple risk factors for a number of diseases it would seem sensible to obtain an INR at least 24 hours prior to providing any care for him. It is always sensible to fully evaluate a patient prior to undertaking any operative care. Whilst guidelines classify risk and discuss safe procedures, it would always be good practice to fully assess and evaluate each patient.

Answer 91

It is not safe to perform a dental extraction on this patient today. There are many factors which will influence our decision. Thus, our interpretation of the INR results presented to us by the patient will allow us as clinicians to facilitate the evaluation of the patient and our subsequent management. 1. The INR Value The INR value today is 4. The SDCEP guidelines state that the INR level should be less than 4 in order for a tooth to be removed safely. 2. Frequency of INR testing Mr Fraser is having his INR taken at 3 day intervals. This would be deemed as a very frequent rate of assessment. This frequency of testing indicates that Mr Fraser is not stable in his warfarin control. This level of unpredictability needs to ne taken into consideration in order to safely manage Mr Fraser and therefore it would be appropriate to have an INR taken no more than 24 hours before the procedure, but ideally as close to the procedure as possible. 3. Variance in INR Value When we assess they level of variability displayed in Mr Fraser’s INR, we can see that the values obtained vary. This variance tells us that Mr Fraser’s control of his warfarin use is not as good as it could be. Therefore, he potentially presents a higher risk of complications. This is an another reason to ensure that you have a valid INR within 24 hours of providing an extraction procedure that may cause post-operative bleeding.

Answer 92

As this value is below 4 and within the therapeutic ratio and appears to have stabilised, it would now be deemed safe to consider the extraction of a tooth. Mr Fraser has a number of teeth to be removed You are now considering removing a tooth. b) Would you change your approach to removing a tooth for this gentleman In order to limit the risk of bleeding the following should be considered: 1. Consider if the drug regime is short or long term. If it is short term only can the tretament be delayed (Mr Fraser’s warfarin use is lifelong) 2. Plan the treatment for early in the day or week in order to allow time for the management of any complications 3. Undertake an atraumatic technique to dental extractions and surgery 4. Use appropriate measure to establish haemostasis 5. Consider the staging of treatment by limiting the initial area of surgery and evaluating haemostasis before proceeding, utilise haemostatic adjuvants and post-operative monitoring 6. Advise on the use of paracetamol analgesia unless contraindicated instead of NSAIDs 7. Provide full written instructions and emergency contact details

Answer 93

SEE PAGE 16 OF HAEMATOLOGY GUIDANCE SHEET TO SEE PROTOCOL FOR MANAGEMENT OF PT'S PRESCRIBED WARFARIN

Answer 94

Planning: Appointment early in the day and early in the week allows for appropriate time for review Check INR – preferably 24 hours before extraction but acceptable up to 72 hours where the INR is stable

Answer 95

Local anaesthetic - A local anesthetic containing a vasoconstrictor should be administered by infiltration or by intraligamentary injection wherever practical. - The use of a short 27-gauge needle will minimise tissue damage. - Regional nerve blocks should be avoided when possible. However, if there is no alternative, local anaesthetic should be administered cautiously using an aspirating syringe. - Local vasoconstriction may be encouraged by infiltrating a small amount of local anaesthetic containing adrenaline (epinephrine) close to the site of surgery. Local haemostasis - Sockets should be gently packed with an absorbable haemostatic dressing: oxidised cellulose (Surgicel®), collagen sponge (Haemocollagen®) or resorbable gelatin sponge (Spongostan®) - Sutures. Resorbable (catgut or synthetic (polyglactin, Vicryl®)) or non-resorbable (silk, polyamide,polypropylene) sutures. Resorbable sutures are preferable as they attract less plaque.47 If non-resorbablesutures are used they should be removed after 4-7 days. - Following closure, pressure should be applied to the socket(s) by using a gauze pad that the patient bites down on for 20 minutes. - Atraumatic technique - The use of tranexamic acid mouthwash, which acts as a local antifibrinolytic agent, is not routinely recommended in primary care

Answer 96

Patients should be given clear instructions (preferably in writing) on the management of the clot in the postoperative period and advised: * to look after the initial clot by resting while the local anaesthetic wears off and the clot fully forms (2-3 hours), * to avoid rinsing the mouth for 24 hours, * not to suck hard or disturb the socket with the tongue or any foreign object, * to avoid hot liquids and hard foods for the rest of the day, * to avoid chewing on the affected side until it is clear that a stable clot has formed. Care should then be taken to avoid dislodging the clot, * if bleeding continues or restarts to apply pressure over the socket using a folded clean handkerchief or gauze pad. Place the pad over the socket and bite down firmly for 20 minutes. If bleeding does not stop, the dentist should be contacted; repacking and resuturing of the socket may be required. * Who to contact if they have excessive or prolonged postoperative bleeding. The surgery and out of hours/on call dentist’s name/number should be provided. There should be a facility for the patient to be reviewed and treated immediately by a dentist if a bleeding problem occurs. If it is not possible for the patient to be seen immediately by a dentist then the patient should be referred to their local accident and emergency department. * On pain control

Answer 97

SEE PAGE 17 HAEMATOLOGY GUIDANCE SHEET

Answer 98

Yes, this drug is different from Warfarin. There is clear guidance available on the management of patients on a DOAC

Answer 99

SEE PAGE 19 HAEMATOLOGY GUIDANCE SHEET

Answer 100

Yes, you should have noted the significant swelling associated with the right knee. Given the context in which you are seeing this patient, a haemophilia and coagulation unit, such a presentation should start alarm bells ringing. It is important that this issue is managed swiftly as an emergency and should take priority over any dental treatment. The swelling is likely to be a hemarthrosis. This is bleeding into a joint space and is associated with haemophilia. Damage to the articular cartilage within the joint is a common consequence of repeated hemarthroses. Intraosseous haemorrhage may lead to bone resorption and the development of bone cysts. This highlights the importance of full assessment of patient. We should evaluate each of patients from the minute they walk in through the door. There are many features of systemic disease which we can observe and will inform our medical risk assessment and ensure we manage patient in a safe and holistic way

Answer 101

At this stage you should have reviewed the medical history form. You should have been left with a number of questions about this patient’s medical conditions and medications. This reinforces the importance of medical history taking. It is only through the systematic interview that we can fully elucidate this gentleman’s medical status. We must find out what his bleeding condition is and its severity. This will determine how we provide his dental care. Perhaps a clue to his condition is the bleeding into the joints he describes. This is potentially Haemophilia. Review of your CMS notes should allow you to remind yourself of the different types of bleeding conditions.

Answer 102

Yes, you need to be able to determine what this gentleman’s bleeding condition is and its associated severity. Whilst you may not be responsible for the provision of blood tests the patient should have had these tests through the Haemophilia centre with which they are registered. There are two types of haemophilia Haemophilia A – deficiency in Fact VIII, most common (85% of all cases) Haemophilia B – deficiency in Factor IX Both forms of haemophilia are x-linked recessive conditions and can only be differentiated through coagulation factor assays The severity of Haemophilia exists across a spectrum: Severe = < 1% Factor present Moderate = 2-5% Factor present Mild = 6-40% Factor present This information should be obtained through a Haemophilia centre

Answer 103

- Periapical Periodontitis 18,26, 46 and 47 - Caries 18,17,27,28,47 - Retained roots 26,46 and 48 - Chronic generalised periodontitis Stage Three – Grade B

Answer 104

Haemophilia: A diagnosis of haemophilia changes the way in which patients are managed completely. Examinations and treatment which does not require manipulation of the mucosa are safe to deliver to patients with this condition. In general, the delivery of supragingival restorations, crowns and bridges with the use of infiltration anaesthesia is safe to provide for people with haemophilia within the general dental practice setting. However, for dental extractions, surgical procedures, subgingival scaling or anaesthesia requiring inferior alveolar nerve blocks of lingual infiltrations it is necessary for these patients to be seen at a dental clinic associated with a haemophilia centre. With these procedures there is an increased risk of bleeding which requiring medical prophylaxis and appropriate monitoring. Consideration should be given to the use of articaine infiltration and intraligamental injections to avoid IANBs. For patient with mild haemophilia or Von Willebrand’s disease, the use of DDAVP is normally undertaken to provide dental procedures which present an increased risk of bleeding. For patients with moderate and severe haemophilia it is likely factor replacement will be required. This affects treatment planning as we wish to reduce the number of times any patient has to be exposed to factor replacement as: - Risk of blood borne infections if plasma derived factor is used although blood products are comprehensively screened (recombinant factor is genetically made and therefore all but negates the risk BBV transmission) - Risk of local site infection - Risk of inhibitors / antibodies developing - Cost Tranexamic acid, an antifibrinolytic agent may also be used in the management of this group of patients.

Answer 105

Dental Factors: 1. Previous disease experience 2. Risk factors and the potential for modification 3. Oral hygiene and use of fluoride

Answer 106

1. Acute management It is essential to manage the gentleman’s swelling and pain. He has not been to the haemophilia unit for many years and therefore they do not have up to date test results for him. In this case it is probably indicated to provide a course of antibiotics until the appropriate assessments and planning can be made in conjunction with the haemophilia unit. 2. Prevention This is essential for any patient but even more so for those individuals with haemophilia as there to prevent the further exposure to factor replacement. 3. Stabilisation of disease Having had the appropriate testing undertaken and liaison with the haemophilia unit the appropriate haematological product can be provided to the patient in order to facilitate the patients care. When treating this group of patients, it is important to attempt to get as much treatment completed when the patient has had medical product. Therefore, if possible it would be ideal to remove at least 46,47 and 48 in one sitting. A quadrant approach to his dentistry would also be valuable in order to reduce the number of appointments and need for medical product. Therefore, a suggest treated plan and staging would be: 1. Prevention and PMPR 2. Appt 1 – Extraction 46,47,48 and consider 18 with subgingival scaling of right quadrants 3. Appt 2 – Extraction of 26, restoration in 27 and 28 with subgingival scaling of left quadrants

Answer 107

1. Prevention 2. Re-evaluation of periodontal condition and subsequent management as required 3. Restoration of spaces as required

Answer 108

1. Prevention 2. Re-evaluation of periodontal condition and subsequent management as required 3. Restoration of spaces as required

Answer 109

Haemophilia A and B Von Willebrand’s Disease

Answer 110

Antiplatelet: Aspirin, Clopidogrel, Prasugrel or Ticagrelor Anticoagulants: Heparin Low Molecular Weight Heparin New or Novel Oral Anticoagulant or Target-specific anticoagulants Coumarin Anticoagulants Other drugs: Side effect of chemotherapy agents in the management of malignancy. HIV or other diseases where the bone marrow is suppressed by the agents used Antimicrobials: Rifampin Anti - seizure medications: Phenytoin, Valproic acid Haloperidol Quinine

Answer 111

Leukaemia Immune Thrombocytopenia Purpura (ITP) Myeloma Infections: Viral infections such as HIV or Hep C

Answer 112

Alcoholic liver Disease Liver Cirrhosis Hepatitis B or C infection Primary Biliary Cirrhosis Hepatocellular carcinoma Changes in both the qualitative and quantitative coagulation factors occur as a result of liver disease. Impaired liver function has an impact upon the hepatic synthesis of clotting factors and proteins involved in the fibrinolytic system including the vitamin K dependent coagulation proteins (II, VII – prolonger PT, shortest half life), IX, X). Thrombocytopenia and thrombocythaemia can also be a feature of liver disease and various mechanisms have been described. - Splenic sequestration - Impaired hepatic synthesis and / or increased degradation of thrombopoietin by platelets sequestered in the congested spleen Alcohol can also have a direct effect to suppress the bone marrow and thus impair the production of cells. (Renal Disease: There are abnormalities in platelet function in renal disease and these are independent of thrombocytopenia. This is poorly understood on the whole but there may well be defects in platelet adhesion, secretion and storage as a result uraemia.)

Answer 113

In the general dental practice setting you would follow the normal protocols. 1. Apply pressure to the socket +/- LA soaked guaze. 2. Pack the socket with a suitable adjuvant material such as oxidised cellulose or a collagen sponge 3. Suture the surgical site 4. Re-evaluate the medical history 5. If available, you could consider a tranexamic mouthwash 6. Cautery – Bipolar/ Silver nitrate sticks. 7. Bone wax If you are unable to arrest a haemorrhage you should consider phoning your local oral surgery or Oral and Maxillofacial Department. If you are in a rural place of work you may well wish to contact your local A and E department if there is no OMFS or oral surgery unit.

Answer 114

As a dental practitioner, unless you have an additional medical degree, we should not be making a medical diagnosis. Whilst, we may be able to see signs and symptoms of medical disease we do not have the training nor the expertise to make a diagnosis in medical specialities. However, the information presented to us should allow us to assess the patient and undertake appropriate medical referrals required and evaluate the safety of performing dental treatment. In terms of communicating this to the patient, we can say his platelets are reduced and that it is likely that this has had impact on his ability to stop bleeding. However, in isolation platelets levels greater than 50 x 10^9/L should still be a safe level to achieve haemostasis following a single uncomplicated tooth extraction. It is therefore probable that there are additional features of this man’s disease which are affecting coagulation. We can only encourage this gentleman to attend his medical assessment and ensure we are kept informed of updates in his medical situation to ensure any dental management can be planned appropriately. In the current situation we cannot provide any operative care for this gentleman until he has been fully assessed from a medical perspective.

Answer 115

Skin: Jaundice, leukonychia, clubbing, palmar erythema, Dupuytren’s contracture, spider naevi Other signs in advancing liver disease: bleeding, oesophageal varices, ascites, peritonitis, encephalopathy or hepatorenal syndrome. Alcohol related: tremors, cognitive impairment

Answer 116

infective: Hepatitis Viruses: A (rarely has significant consequences) B,C and D Non-infective: Autoimmune – Primary Biliary Cirrhosis Alcohol related Non-alcoholic fatty liver disease Haemochromatosis Drug induced Hepatocellular carcinoma Stages of Liver Disease (at its most basic level!) Hepatitis: Inflammation of the liver which may or may not be reversible depending on the disease → Liver cirrhosis Irreversible liver necrosis and fibrosis → Liver failure Failure of normal liver function

Answer 117

The United Kingdom Model for End Stage Liver Disease (UKELD) is a system which predicts a person’s prognosis in chronic liver disease and is used as to guide determine the need for liver transplant. Current guidelines in Scotland advise that a UKELD score of 49 is the minimum level at which a patient should be assessed for a liver transplant. This score also equates to > 9% mortality rate within 12 months. From a dental perspective we can now determine that this person has a significant level of liver disease which will have implications on the rest of the body. This may interfere with the way in which we provide any dental treatment and subsequently significant planning will be required to facilitate his treatment.

Answer 118

1. It is important to liaise with the hepatology unit to establish the medical condition of this gentleman and to be able to work together to ensure this gentleman receives appropriate medical care to facilitate safe dental treatment in the correct environment. 2. Blood tests: FBC, Coagulation/clotting screen (PT + ration, APTT + ratio, thrombin time,TCT ratio) +/- INR , LFTS , Us and Es 3. Appropriate radiographs: OPT +/- intraoral views as required, full mouth pocket chart if required after bloods.

Answer 119

Review your previous CMS teaching on blood tests and results. In this answer we will only highlight key points i) Reduced RCC, Hb and haematocrit with an increased MCV = anaemia, Vit b12/ Folate deficiency ii) Platelets are reduced iii) LFTS – deranged iv) Coagulation screen – prolonged PT and APTT v) Us and E – raised chloride

Answer 120

This patient has reduced platelets and prolonged PT, APTT and his LFTS are deranged. The interpretation of these results means that this person will require multidisciplinary care to ensure that he will stop bleeding should we undertake any operative treatment. This will include any subgingival scaling or extractions. As previously mentioned, whilst his platelets are over 50 x 10^9/L , a level seen as safe in secondary care to remove a tooth, he has other defects in the haemostatic mechanism which increase his risk of bleeding. These need to be managed and thus he is not safe to treat in primary care.

Answer 121

SEE PAGE 6/7 LIVER AND RENAL GUIDANCE SHEET

Answer 122

1. Where should this gentleman be treated? - He is not suitable to be treated in the primary care environment - He should be assessed and treated in a hospital in association with a hepatology unit and appropriate medical back up - The risk to be bleeding is significant and therefore he may require a bed such that he can be assessed and monitored pre- and post-operatively by medical colleagues. 2. This gentleman is likely to require some form of product to facilitate any treatment which may result in bleeding. There is a significant risk he may not stop bleeding if teeth are removed without this. Different products are used and the plans put in place are individual to the patient. Some of the different methods used are: - Vitamin K replacement - FFP transfusion - +/- platelets transfusion Treatment planning should be considered when a patient requires medical product. You wish to do as much treatment as possible when a person is given product as transfusion come with associated risks. However, you must balance this with the risk of bleeding, volume of local anaesthetic given and what the patient can cope with.

Answer 123

SEE PAGE 7/8 LIVER AND RENAL GUIDANCE SHEET

Answer 124

1. Benefit 2. Minimum necessary intervention 3. Take account of the wishes of the adult 4. Consultation with relevant others 5. Encourage the adult to exercise ‘residual capacity’

Answer 125

1. Benefit 2. Minimum necessary intervention 3. Take account of the wishes of the adult 4. Consultation with relevant others 5. Encourage the adult to exercise ‘residual capacity’

Answer 126

1. Benefit 2. Minimum necessary intervention 3. Take account of the wishes of the adult 4. Consultation with relevant others 5. Encourage the adult to exercise ‘residual capacity’

Answer 127

- A framework for safeguarding the welfare and managing the finances of adults who lack capacity due to mental illness, learning disability or a related condition, or an inability to communicate. - The Act aims to protect people who lack capacity to make particular decisions, but also to support their involvement in making decisions about their own lives as far as they are able to do so.

Answer 128

- This act only comes into action where an adult is incapable of making a decision for themselves - The act provides a range of ways to authorise someone else to make the decision for that incapable adult - Only applicable to Scotland – Ireland, Wales and England are different - Part 5 of the act covers medical (including dental) treatment - Allows the Sheriff court to appoint guardians; oversee attorneys and resolve disputes

Answer 129

- In terms of healthcare, competent adults have the right to refuse treatment - Failure to treat adults who do not have capacity may constitute negligence - everyone has it until proven otherwise

Answer 130

- Inability of an adult to enter into legally binding contracts - “Adult” means a person who has attained the age of 16yrs 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

Answer 131

- Presume capacity - Is decision or action specific - Not “all or nothing” - Capacity may fluctuate - Consider residual capacity - Record your assessment - Gather evidence from a range of sources and - - - listen carefully to what the patient is telling you - Keep language appropriate - Break up information into sections (chunk) - Ask the patient to explain to you what you have discussed with them (check) - Assess retention – ask the patient at another appointment - Seek advice when needed - Be open minded and methodical

Answer 132

- If a patient has a “mental disorder” – mental illness, learning disability, dementia, acquired brain injury, autistic spectrum disorder - If a person cannot communicate due to a physical disorder even with assistance – locked in syndrome, unconscious following an accident.

Answer 133

Being incapable of: - Acting - Making a decision - Communicating decision - Understanding decision - Retaining the memory of decision = AMCUR

Answer 134

- Understand in simple language what the treatment is, its purpose and nature and why it is being proposed - Understand its principle benefits, risks and alternatives; - Understand in broad terms what will be the consequences of not receiving the proposed treatment - Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision (Scotland – “retain the memory of the decision”)

Answer 135

Any action or decisions taken must benefit the adult and only be taken when that benefit cannot reasonably be achieved without it: - Any treatment must benefit the patient - Without treatment that benefit would not be possible - Any intervention must improve or enhance their life

Answer 136

- Any action or decision taken should be the minimum necessary to achieve the purpose. - It should be the option that restricts the person’s freedom as little as possible - We must always seek to avoid the most invasive treatments, when simpler alternatives are available and likely to be successful - It does not refer to the simplest or least complex solution. - Minimum intervention would be discrimination by not offering all treatment

Answer 137

- We must try and find out what the patient previously (or currently) wanted regarding their dental treatment. - Are there relatives or close friends who can help us find out? - Ask the patient - Look for a patient passport or care home notes? - Is their mouth heavily restored – does this show previous investment in dental treatment?

Answer 138

- We may not know the patient that well. - The patient’s family, friends, guardian, attorney or other people of relevance are likely to know the person much better. - Relevant others should be consulted with regard to what they think that the patient would have wanted

Answer 139

- The nearest relative and primary carer of the adult - Any guardian, continuing attorney or welfare attorney of the adult who has powers relating to the proposed intervention - Any person whom the sheriff decides - Any other person appearing to the person responsible for authorising or effecting the intervention to have an interest in the welfare of the adult or in the proposed intervention.

Answer 140

- We must identify if there are any decisions which the patient can make for themselves - In so far as it is reasonable or practicable to do so, encourage the adult to exercise whatever skills he or she has concerning property, financial affairs or personal welfare as the case may be, and to develop new such skills.

Answer 141

A suitable adult substitute decision maker for someone without capacity

Answer 142

Power of Attorney: - Continuing Power of Attorney – cannot consent for dental treatment - Welfare Power of Attorney – can consent for dental treatment - Combined Power of Attorney – can consent for dental treatment - These are granted while a patient has capacity for someone to act on their behalf should the need arise - Powers are dormant until demonstrated they are needed - No expiry date - This can be done via a lawyer and does not need to go to court - Will be registered with the Office of the Public Guardian (OPG) - Can be more than one person - Normally indefinite once the adult does not have capacity - Often a family member or trusted friend

Answer 143

Guardianship Orders: - Welfare Guardian – can consent for dental treatment - Financial Guardian – cannot consent for dental treatment - Court appointed person to make decisions on behalf of an adult with incapacity - Appointed by Sheriff after the adult has lost capacity - Requires 2 medical reports - Continuous management of welfare and financial matters - Powers to deal with property, finance and even marital affairs - Usually appointed for three years - E.g. A person with a learning disability who turns 16 – their parents may need to apply for guardianship.

Answer 144

Only covers financial affairs and property Cannot consent to dental treatment

Answer 145

- Only comes into affect if the adult loses capacity - Must take into account the adults wishes - Welfare decisions including healthcare, dressing, eating - Can consent to dental treatment

Answer 146

- Patients with capacity - Welfare Powers of Attorney - Welfare Guardians - Medical & Dental* practitioners under Section 47 of AWI Act (General Authority to Treat)

Answer 147

- Provided a valid certificate of incapacity is issued for the treatment given AND - Provided the principles of the Act are observed… Treatment may be given - Common law allows medical treatment to be given in an emergency to patients who cannot consent

Answer 148

- Medical practitioner primarily responsible for the patients care (GMP) - Consultant in charge of the patients care -Dental practitioners* - Registered nurses* - Optometrists*

Answer 149

- A certificate issued by ‘other’ healthcare professionals is only valid for their area of practice - A dentist can only authorise dental treatment - A dentist can only complete a section 47 form if they have completed the required training - Even where a proxy has been appointed a Certificate of Incapacity MUST also be completed

Answer 150

- Unlikely to have power to sign AWI section 47 form - Therefore required to liaise with GMP - The GMP should assess capacity of the patient - If satisfied of incapacity GMP should provide you with an Adults with Incapacity form - Provide GMP with details to avoid inappropriate generalisation

Answer 151

- Discuss treatment and consult with power of attorney, welfare guardian or nearest relative - If agreeing to treatment you must request a capacity assessment and provision of a Section 47, Adults with Incapacity Certificate from the General Medical Practitioner - They should confirm status of POA and observe legal documents confirming status - It is possible to provide a treatment plan to the GMP on the form allowing them to sign the course of the treatment

Answer 152

- AWI can last up to 3 years - For lifelong and progressive conditions where no capacity is likely to be regained, it is sensible to have an AWI certificate running for dental examination for this time period - For individual courses of treatment a separate certificate should be completed limited to the time period for the estimated completion of treatment.

Answer 153

- AWI can last up to 3 years - For lifelong and progressive conditions where no capacity is likely to be regained, it is sensible to have an AWI certificate running for dental examination for this time period - For individual courses of treatment a separate certificate should be completed limited to the time period for the estimated completion of treatment.

Answer 154

1. Opinions on the contents of the letter - What are the group’s initial feelings towards the situation? Perhaps the student perspective brings a lot of questions and apprehension to managing this situation? How do they feel about treating someone with a dementia? How does the group feel about being given a letter by the daughter? 2. What are the potential difficulties they foresee in a patient with dementia? Important at this stage to describe dementia as a disease and develop understanding Difficulties: a) Capacity to Consent  Can you assume this lady does not have capacity without examining her  decision is specific and the patient s assumed to have capacity until proven otherwise b) Co-operation for treatment c) Treatment planning Mrs Smith has Alzheimer’s a form of dementia. Alzheimer’s is the most common form of dementia. Dementia is currently under diagnosed in our population. The aging global population is predicted to result in an explosion of people with dementia. Other types include: Vascular, Dementia with Lewy Bodies, Korsakoff’s syndrome Dementia is a chronic organic brain disease which is progressive and causes loss of cognitive and motor functions. Clinical presentations: 1st stage - memory loss, disorientation in time and place, judgment impaired 2nd stage – loss of intellect, aphasia, inability to clothe or feed oneself, acquired defects of visual- spatial skill 3rd stage – apathy, inability to communicate, anxiety, depression, absolute dependence

Answer 155

1) Speak to Mrs Smith; she is your patient and the person at the centre of care Can she tell you why she is here? Or anything about her history? Consider C/O, H/P/C, MH, SH (smoking/ alcohol / begin capacity assessment) How do you take a history in this situation? If she is unable to give you any information what would you do? Examination -> Do you perform this in the dental chair or wheel chair -> What influences this choice -> Do you examine someone with dementia differently ( dependent on mood / timing/ communication skills 2) Speak to Denise, the carer She might have some very useful information The response of carers can be very variable but some are very well informed and know a lot about their clients Denise, the Carer advises: “Mrs Smith has been up during the night for the last few weeks, we have found her crying at night and pulling at her lower lip. She hasn’t been eating her food, which is really unlike her. She has been a wee bit more pushy with some of the other residents too, normally she’s dead gentle but recently she’s just not been herself. “

Answer 156

Someone with dementia may not be able to tell you about their pain or give you an accurate history or any history at all. Therefore, it is important to look for other indicators or signs which may suggest a dental problem. Someone unable to communicate pain may exhibit signs by: a) Holding face b) Pull at face c) Is she eating normally d) Altered sleeping pattern e) Exhibiting abnormal / changes in behavior

Answer 157

Pain and infection – abscessed 36(most likely source of pain) , draining sinus 44(less of a priority as it is already draining?) Ulcer Prevention (specific question later related to this) Periodontal disease Retained roots Angular Cheilitis and Erythematous Candidiosis of the Palate Denture hygiene and fit

Answer 158

Most likely to be from the buccal abscess associated with the retained roots of tooth 36 . It is essential to get the patient out of pain today. Discuss potential management and consider both coopertation and capacity.

Answer 159

What are the possible causes of the ulcer present? How would you manage this? 1. Trauma - most likely as adjacent to 45 and 46 rough teeth? - Management smooth with polishing disc if possible or place a Glass Ionomer dressing. Is extraction justified? 2. Medications – Fe tablets? Aspirin? Can the patient swallow tablets? She also has a very dry mouth which inhibits the swallowing action 3. Oral Cancer

Answer 160

Angular cheilitis Aetiology: fungal/ bacterial – role of decreased OVD Management: need to improve OVD? Topical management with antifungal – fusidin, miconazole gel

Answer 161

Role of medications: bendroflumethiazide in this instance Management: unlikely that this patient is going to have her medications altered Ruling out other causes of dry mouth is important – eg. Dehydration can be an issue with the elderly group, Sjogrens Saliva substitutes: ensure hydration water is best , saliva orthana, biotene

Answer 162

Erythematous candidosis The denture is a number of years old and is not cleaned Candidal hyphae can penetrate into the acrylic of dentures Management: 1. Good denture and oral hygiene – run through this with the carer 2. Importance of disrupting the biofilm – cleaning the palate with a brush and the denture – Local measures first 3. Use of chlorhexidine 4. Consider topical therapy – miconazole gel, in denture. Is co-operation good enough for nystatin or amphotericin? Unlikely to have co-operation to allow this. Consider tea tree oil? Other naturals? 5. Systemic agent – consider interactions

Answer 163

Abscess, draining sinus and a number or retained roots. It is in the best interest of this patient to receive dental care in order to prevent further dental infection and she has a number of teeth which present a potential risk of infection for the future. Discuss with the students the potential management strategies

Answer 164

31 may well be causing a problem for eating and maybe an aspiration risk. Consider extraction? Discuss management strategies for the remaining periodontally affected teeth SEE PAGE 7 NERUOLOGY prevention

Answer 165

Mrs Smith is unable to provide her own self care Therefore the care home has a responsibility to aid her in this. Use of an oral health team can break down some of the barriers currently in place. Consider: High strength fluoride Labeling a new denture if made

Answer 166

Encourage positive relationships. Discuss some of the barriers to care in residential homes: 1) Under trained staff 2) Poorly paid 3) Volume of work 4) Own perceptions of oral health Consider if the care home would get on board with more help with oral health. Either as a GDP you could develop a strong link or consider creating communication with PDS who can facilitate help.

Answer 167

SEE PAGE 8 NEUROLOGY GUIDANCE NOTES

Answer 168

SEE PAGE 11 NEUROLOGY GUIDANCE NOTES

Answer 169

important to contact Mrs Smith daughter as she has contacted you with concerns She may well be a proxy ( welfare guardian / next of) and it is important to decipher this ( check paper work) Discuss: 1. What if patient has capacity, would confidentiality be compromised if you spoke to the daughter 2. Can you address all the issues on the daughter’s list? Dental health is clearly a priority. However, unless as a dental professional you feel that the treatment will benefit Mrs Smith then you should not provide it 3. If Mrs Smith’s daughter is not aware of AWI it can often be quite disconcerting that someone is signing a form of incapacity. Families often feel they are losing control. It is important to discuss the use of the certificate with Mrs Smith’s daughter

Answer 170

- Caring for Smiles is Scotland’s national oral health promotion, training and support programme, which aims to improve the oral health of older people, particularly those living in care homes. - Provides oral care training for care home staff to ensure they know how to look after the oral health of their residents. This requires regular assessment of an individual’s mouth and the development of a care plan with details of his or her particular needs.

Answer 171

- bridging - describe and show toothbrush to residents, mimic brushing your own teeth - chaining - this involves gently bringing the residents hand to mouth while describing activity - hand over hand - if chaining not success place hand over reside and gently brush

Answer 172

- bridging - describe and show toothbrush to residents, mimic brushing your own teeth - chaining - this involves gently bringing the residents hand to mouth while describing activity - hand over hand - if chaining not success place hand over reside and gently brush - distraction - if none of these strategies work, then try distracting the resident - rescuing - if attempts are not going well, the care assistant can leave and the rescuer comes in to take over. someone with a fresh approach

Answer 173

- Loss of short-term memory - Confusion, poor judgement, unwilling to make decisions - Anxiety, agitation or distress over perceived changes - Inability to manage everyday tasks. - Communication problems – a decline in ability or interest in talking, reading and writing.

Answer 174

- More support required, including reminders to eat, wash, dress and use the lavatory; - Increasingly forgetful and may fail to recognise people; - Distress, aggression, anger, mood changes – frustration; - Risk of wandering and getting lost, leaving taps running, gas unlit, cooking unattended or forgetting to light the gas; - May behave inappropriately e.g. Going out in nightclothes; - May experience hallucinations, throw-back memories.

Answer 175

- Inability to recognise familiar objects, surroundings or people – but there may be some flashes of recognition. - Increasing physical frailty, may start to shuffle or walk unsteadily, eventually becoming bed/wheelchair confined. - Difficulty eating and sometimes swallowing, weight loss. - Incontinence and gradual loss of speech. - Symptoms are progressive and irreversible.

Answer 176

- Acute: Nil - Stabilisation: PMPR -Prevention: Diet; OHI; Fluoride Extraction of poor prognosis teeth Restorations - Maintenance: Review Perio and OH - Reconstructive: Immediate P/ -

Answer 177

What if patient had poor cooperation or none? Is sedation or GA an option? Is patient symptomatic? Time since diagnosis? Aspiration risk of mobile crowns? Residual capacity / Communication How will we know if the patient is in pain? Is no treatment neglect?

Answer 178

Can you describe to someone else how to brush another persons teeth? How would you describe removing a denture from a patients mouth to a carer so they can clean it?

Answer 179

- Comfort when eating - Difficulty in performing oral hygiene - Risk of malignant transformation - Management of disease cannot just stop because they have dementia - Can the Oral Medicine Consultant perform domiciliary care? - Systemic disease and polypharmacy may contraindicate certain therapies

Answer 180

aspiration pneumonia

Answer 181

Dementia is a syndrome – usually of a chronic or progressive nature Deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing. Dementia is an acquired progressive loss of cognitive functions, intellectual and social abilities Severe enough to interfere with daily functioning,

Answer 182

Characterized by: Amnesia (especially for recent events), Inability to concentrate, Disorientation in time, place or person, Intellectual impairment

Answer 183

- alzheimer's - vascular - dementia with lewy bodies - frontotemporal - rare forms like HIV – related genitive impairment Parkinson’s disease Corticobasal degeneration Multiple Sclerosis Niemann-Pick disease Creutzfeldt-Jakob disease

Answer 184

Reduction size of the Cortex, severe in hippocampus Plaques are deposits of a protein fragment called beta-amyloid that build up in the spaces between nerve cells. Tangles are twisted fibers of tau protein build up inside cells. Distinctive Features: STML, Aphasia, Communication Difficulties, Muddled over everyday activities, mood swings, withdrawn, loss of confidence

Answer 185

Vascular dementia is caused by reduced blood flow to the brain, which damages and eventually kills the brain cells. This can develop as a result of: - narrowing and blockage of the small blood vessels deep inside the brain (known as small vessel disease) - a single large stroke (where the blood supply to part of the brain is suddenly cut off) - lots of mini-strokes that cause tiny, but widespread, damage to the brain - In many cases, these problems are linked to underlying health conditions – such as high blood pressure and diabetes – as well as lifestyle factors, such as smoking and being overweight. - Distinctive Features: Memory problem of sudden onset, visuospatial difficulties, anxiety, delusions, seizures

Answer 186

Deposits of an abnormal protein called Lewy bodies inside brain cells. These deposits, which are also found in people with Parkinson’s disease, build up in areas of the brain responsible for things such as memory and muscle movement. Distinctive Features: STML, Cognitive ability fluctuates, visuospatial difficulties, attentional difficulties, overlapping motor disorders, speech and swallowing problems, sleep disorders, delusions

Answer 187

The frontal lobes of the brain, found behind the forehead, deal with behaviour, problem-solving, planning and the control of emotions. Changes in personality and behaviour, and difficulties with language. Younger age of onset Ubiqitin associated clumps of protein TDP-43 Distinctive features: STML not always present, uncontrollable repetition of words, mutism, repetition of words of other people, personality change, decline in personal and social conduct

Answer 188

More support required, including reminders to eat, wash, dress and use the lavatory; Increasingly forgetful and may fail to recognise people; Distress, aggression, anger, mood changes – frustration; Risk of wandering and getting lost, leaving taps running, gas unlit, cooking unattended or forgetting to light the gas; May behave inappropriately e.g. Going out in nightclothes; May experience hallucinations, throw-back memories.

Answer 189

Inability to recognise familiar objects, surroundings or people – but there may be some flashes of recognition. Increasing physical frailty, may start to shuffle or walk unsteadily, eventually becoming bed/wheelchair confined. Difficulty eating and sometimes swallowing, weight loss. Incontinence and gradual loss of speech. Symptoms are progressive and irreversible.

Answer 190

Dementia screen to eliminate treatable causes - FBC, U&E's, kidney, liver and thyroid function tests Glucose, serum B12, Folate and Calcium, C-Reactive Protein and Urinalysis If indicated - Syphilis serology, autoantibody screen, serum cholesterol and CT Neurological examination and detailed cognitive testing (MMSE).

Answer 191

pros Well known Easy to administer Samples range of cognitive functions Test-re-test and inter rater availability cons - Only three words are to be remembered on recall – not sensitive to mild impairment - Old – new knowledge ? - Non standardised time between registration and recall - Not sensitive in testing frontal lobe

Answer 192

There is no pharmacological, surgical or behavioural cure Counselling may delay residential care by up to 1 year Aspirin and reducing cardiac risks (control of BP, weight, exercise etc..) may halt deterioration of vascular type dementias. Non Steroidal Anti Inflammatory Drugs (NSAIDs) may slow progression. Vitamin E and Ginko Biloba may slow progression.

Answer 193

Anticholinesterases: Donepezil (Aricept®), galantamine, rivastigmine (Exelon®) for mild/moderate Alzheimer’s May delay admission to residential care, assist in behavioural difficulty, defer deterioration in cognition Specialist instigation and review. 1 in 3 on these drugs? Treatment should continue until the patient, carer, and/or specialist decide it is the right time to stop, if it is not working, or if the person's MMSE score falls below 10.

Answer 194

Frailty is defined as ‘a state of increased vulnerability to stressors due to age related declines in physiological reserve across neuromuscular, metabolic, and immune systems’

Answer 195

Extremes of age Concurrent use of corticosteroids Systemic conditions affecting bone turnover Malignancy Coagulopathies, chemotherapy, radiotherapy Duration of therapy Previous diagnosis of BRONJ Potency of drug Invasive dental procedures Denture trauma Poor oral hygiene Periodontal disease Alcohol or tobacco use Thin mucosal coverage

Answer 196

Advise patient of MRONJ risk Informed consent Emphasise rarity of condition Don't discourage from taking medication Regular dental checks Maintain good oral hygiene Limit alcohol and stop smoking Report any symptoms (e.g. loose teeth, pain, swelling)

Answer 197

Antidepressants Gabapentin Carbamazepine Topical capsaicin 0.025% Transcutaneous electrical nerve stimulation (TENS)

Answer 198

about the high morality in care homes

Answer 199

Intellectual disability involves problems with general mental abilities that affect functioning in two areas: * Intellectual functioning (such as learning, problem solving, judgement) * Adaptive functioning (activities of daily life such as communication and independent living)

Answer 200

In the context of health experience an impairment is any loss or abnormality of psychological, physiological or anatomical structure or function. Impairment is considered to occur at the level of organ or system function. Disability is concerned with functional performance or activity, affecting the whole person.

Answer 201

In the context of health experience a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being

Answer 202

Disability is caused by the way society is organised, rather than by a person’s impairment or difference.

Answer 203

 The medical model of disability says people are disabled by their impairments or differences.  Under the medical model, these impairments or differences should be 'fixed' or changed by medical and other treatments,

Answer 204

 The medical model of disability says people are disabled by their impairments or differences.  Under the medical model, these impairments or differences should be 'fixed' or changed by medical and other treatments,

Answer 205

 The medical model of disability says people are disabled by their impairments or differences.  Under the medical model, these impairments or differences should be 'fixed' or changed by medical and other treatments,

Answer 206

 The medical model of disability says people are disabled by their impairments or differences.  Under the medical model, these impairments or differences should be 'fixed' or changed by medical and other treatments,

Answer 207

- Antenatal screening and subsequent termination have resulted in the total number of live DS births decreasing (Morris and Alberman, 2009). - The single greatest risk factor for DS is advanced maternal age (Sherman et al., 2007). - Women over the age of 35 are more likely to have a child with DS with the risk continuing to increase with advancing age.

Answer 208

* Congenital Heart Defects * Alzheimer’s Dementia * Epilepsy * Leukaemia * Hearing impairment * Diabetes Mellitus * Ceoliac Disease * Thyroid Disease * Intellectual Impairment

Special Care Dentistry Flashcards

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