Special Care Dentistry

Question 1

Define what an impairment is

Answer 1

impairment is concerned with abnormalities in the structure or functioning of the body or its parts. Any loss or abnormality of psychological, physiological or anatomical structure or function

Question 2

Define what is meant by disability

Answer 2

disability is concerned with the performance of activities; a restriction or lack (resulting from an impairment) of ability to perform an activity in a manner or within the range considered normal

Question 3

Define what is meant by handicap

Answer 3

handicap is concerned with the broader social and psychological consequences of living with impairment and disability. A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, social and cultural function) for the individual

Question 4

What Acts are in place to protect people with a disability?

Answer 4

The Equality Act (2010) Disability Discrimination Act (2004)

Question 5

From what discrimination does the Equality Act protect people?

Answer 5

Discrimination against; age, pregnancy or having a child, disability, race, religion/belief or lack of, sex, sexual orientation

Question 6

In relation to the Equality Act, what are protected situations?

Answer 6

At work, in education, as a consumer, when using public services, when buying or renting property, as a member or guest of a private club

Question 7

What is the aim of the Disability Discrimination Act?

Answer 7

to end the discrimination which many disabled people face. This act gives disabled people rights in the area of; employment, access to goods, facilities and services, buying or renting property

Question 8

What is autism?

Answer 8

• Life long developmental disability - Affects area of brain controlling language, social interaction and creative and abstract thinking -Affects how a person communicates with and relates to people and the world around them

Question 9

What are some features of autism?

Answer 9

-Impaired communication, social interaction, social imagination -hyper/hyposensitivity - Love of routine - Special interests - Special talents - Learning disability - Association with epilepsy, tuberous sclerosis and fragile x - Diet

Question 10

How should preventive advice and treatment be offered to patients with Autism?

Answer 10

• Dietary advice - OHI (timing, method) -Unflavoured toothpaste (oranurse) -Extra fluoride if high caries rate or if providing treatment likely to be difficult ( 2 x yearly fluoride varnish. Daily fluoride mouthwash 0.05%F) -2,800/5,000 ppm fluoride toothpaste

Question 11

What should be taken into consideration if a patient with autism requires GA/sedation?

Answer 11

-Avoid if possible. -Issues to consider; capacity to consent, use of pre-meds eg temazepam, midazolam. Clinical holding -Most dental treatment is possible but need to be confident that treatment will be successful and last -Other procedures can be done at the same time such as blood tests, ECG, podiatry

Question 12

What is the adults with incapacity act?

Answer 12

-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

Question 13

Define capacity

Answer 13

-The ability or power to; Receive impressions. Receive knowledge. Do or understand something

Question 14

Define incapacity

Answer 14

-Incapable of; Acting. Making decisions. Communicating decisions. Understanding decisions. Retaining the memory of decisions

Question 15

How can capacity be demonstrated?

Answer 15

-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 treatment proposes -Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision

Question 16

What are the five principles of the adults with incapacity act?

Answer 16

1) Benefit 2) Minimum necessary intervention 3) Take account the wishes of the adult 4) Consultation with relevant others 5) Encourage the adult

Question 17

Who is a power of attorney?

Answer 17

• Granted by the adult while s/he still has capacity - Can be a family member or a trusted frient - Similar procedure to making a will - Certified by a lawyer or medical practitioner - Registered with the Public Guardian - Referred to as a proxy

Question 18

What is a welfare power of attorney?

Answer 18

-Powers only come into effect when the adult is incapable of decision making -Must take into account the adults wishes - Matters relating to health and personal welfare - Must be registered with the office of the public guardian

Question 19

What is continuing power of attorney?

Answer 19

Only covers financial affairs and property

Question 20

What is a guardianship order?

Answer 20

• Court appointed - Requires two medical reports - Continuous management of welfare and financial matters - Powers to deal with property, finance and even marital affairs - Usually appointed for 3 years

Question 21

How can oral cancer present in appearance?

Answer 21

• Ulceration - White patches, red patches, mixed patches - Texture - Firm/fluctuant - Rolled margins, induration (hardened)

Question 22

What are some oral manifestations of hamatological malignancy?

Answer 22

-Gingival swelling - Mucosal pallor - Spontaneous bleeding - Petechia (purple/red spots) - Oral ulceration - Infections that are recurrent or severe (viral, fungal, bacterial)

Question 23

What should be considered in an oral cancer dental pre-assessment?

Answer 23

• Remove infectious dental foci before the start of cancer therapy -Prepare the patient for expected side effects of cancer therapy - Management of the side effects of cancer therapy short/long term - Establish good oral hygiene to meet the increased challenge - Restoration? - Plan for maintaining oral hygiene, providing preventive care, completing oral rehabilitation and follow up

Question 24

What are some oral affects of cancer treatment?

Answer 24

The mouth is a potential source of infection which can be life threatening in immunocompromised patients. A potential portal of entry - Mouth is often too sore to eat and clean during therapy - Xerostomia and risk of further dental disease -Provision of dental treatment difficult during chemotherapy - Effects of chemo on blood cells - High risk of complications

Question 25

What is the advice on extractions prior to cancer therapy?

Answer 25

• Wherever possible, teeth should be removed no less than ten days prior to cancer therapy, ideally three weeks. - Use an atraumatic technique - Achieve primary closure - Every measure should be put in place to aid quick healing of sockets and surgical sites

Question 26

What is the advice on restorations prior to cancer treatment?

Answer 26

• Where possible this should be with a definitive material - If timescale is limited, consider GI as a provisional - Teeth and restorations should be smoothed; rough teeth can be very painful during period of mucositis - Can result in ulceration; portal of entry for infections

Question 27

What is mucositis?

Answer 27

• Acute inflammation of the mucosa -Onset; Radiotherapy 12-15 days after first dose of treatment. Chemotherapy 1 week after first dose of treatment

Question 28

What are some preventive measures that can be taken against mucositis?

Answer 28

-Improved OH reduces healing time -Ill fitting dentures/sharp restorations should be adjusted -Mucosal sheilds (if radiotherapy)

Question 29

How can mucositis be managed?

Answer 29

-Difflam spray (Benzydamine hydrochloride mw 0.15%) - 2% lidocaine mw prior to eating -Gelclair -Chlorhexidine - Ice chips for 30 mins prior to treatment

Question 30

What are the implications of xerostoma following cancer treatment?

Answer 30

-Saliva can become thick, acidic and viscous; loss of protective features of saliva. -Radiotherapy can last two years or greater following treatment. May be permanent -Chemotherapy; salivary flow tends to return within two months. -Saliva can be stimulated or saliva replacements used

Question 31

What are the features noticed in a patient with Parkinson’s?

Answer 31

• Mask like face
• Slow speech and difficulty swallowing
• Impaired dexterity
• Abnormal posture and difficulty walking – shuffling Gait
• Memory problems

Question 32

What is the dental relevance of Parkinson’s disease?

Answer 32

• Difficulty accepting treatment:
  — Tremor of the body at rest
  — Often facial remorse reduces on purposeful movement
  e.g. mouth opening
  — Lack of control of oral muscles
• Dry mouth common due to anti-cholinergic effects of drug
  treatment (Benztropine)
• Increased risk of drug interactions

Question 33

What are the signs that a patient is in pain that can’t communicate well?

Answer 33

• General signs:
  — Fidgeting, pacing, repetitive motions, refusal to eat,
  crying and groaning, refusal to cooperate
• Facial signs:
  — Frowning, grimacing, teeth clenching, biting and
  rubbing area that is sore
• Behavioural signs:
  — Aggressive behaviour, depression, isolation, sleep
  disturbances and withdrawal

Question 34

What is the difference between a patient with Parkinson’s and a patient with
cerebral palsy with regards to tremors?

Answer 34

• Parkinson’s typically presents with intention tremors and
  Parkinsonism tremor at rest:
  — Intention tremor is present when tremor amplitude
  increases during visually guided movements towards a
  target at the termination of movement
• Ataxia Cerebral palsy typically presents with action intentional
  tremors which is especially apparent when carrying out precise
  movements.

Question 35

What are the types of dementia?

Answer 35

• Alzheimer’s:

— Reduction in the size of the cortex, severe in

hippocampus

— Presence of Plaques which are deposits of protein

fragments of beta-amyloid that builds-up in the spaces

between the nerve cells and tangles which are twisted

fibres of tau protein build-ups inside cells

• Vascular:

— Caused by reduced blood flow to the brain, which

damages and eventually kills the brain cells

• Dementia with Lewy bodies:

— Deposits of an abnormal protein – Lewy bodies – inside

the brain cells

• Frontotemporal:

— The frontal lobe has associated ubiquitous associated

clumps of protein linked with TDP-43 found on it.

• Rarer forms:

— HIV – related genitive impairment

— Parkinson’s disease

— Corticobasal degeneration

— MS

— Niemann-pick disease

— Creutzfeldt-Jakob disease (CJD)

Question 36

What legislation protects dementia?

Answer 36

• The human rights act 2000
• Disability discrimination act 2005
• The equality act 2010
• The adults with incapacity act (Scotland)
• The mental capacity act (England and Wales)

Question 37

Who is involved in the multi-disciplinary team care for patients with dementia?

Answer 37

• GP
• Dentist
• Consultant neurologist
• Dementia nurse
• Macmillan nurse when in late stages
• Physiotherapists
• Careers

Question 38

What are the symptoms of early, middle and late stage dementia?

Answer 38

• Early:

— Symptoms are often misattributed to stress,

bereavement or normal ageing which include:

i. Loss of short term memory
ii. Confusion, poor judgment, unwilling to make

decisions

iii. Anxiety, agitation or distress over perceived

changes

iv. Inability to manage everyday tasks
v. Communication problems – decline in ability or

interest in talking, reading and writing

• Middle:

— Increased obvious symptoms:

i. More support required including reminders to

eat, wash, dress and use the toilet

ii. Increasingly forgetful and may fail to recognise

people

iii. Distress, agression, Anger, mode changes –

frustration

iv. Risk of wandering and getting lost
v. May behave inappropriately e.g. going out in

nightclothes

vi. May experience hallucinations, throw-back

memories

• Late:

— Much more progressive symptoms:

i. Inability to recognise familiar objects,

surroundings or people

ii. Increasing physical frailty, may start to shuffle

or walk unsteadily

iii. Difficulty eating and sometimes swallowing,

weight loss associated incontinence and gradual

loss of speech

iv. Symptoms are progressive and irreversible