clinic theory II exam II

tobacco cessation

• when a person stops tobacco use with the goal of achieving permanent abstinence

• majority of people cycle through multiple periods of abstinence and then relapse

tobacco dependance

• chronic disorder characterized by vulnerability to relapse that persists for months

80% of lung cancer deaths

• attributed to smoking

systemic health effects

• nicotine addition

  • cancer

  • cardiovascular disease

  • hypertension, stroke

  • respiratory disease

  • reproductive problems

  • impotence

  • ulcers

  • osteoporosis

  • facial wrinkling

metabolism of nicotine

• nicotine is absorbed through the lungs

• distributes to brain, liver, spreads to nearly all body tissues

components of tobacco products and tobacco smoke

• nicotine

• carcinogenic substances

• cigarette smoke

chemical compounds of nicotine and tobacco products can be

• carcinogenic

• respiratory toxicant

• cardiovascular toxicant

• reproductive or developmental intoxicant

• addictive

smokeless tobacco is

• absorbed in the oral cavity and intestines

systemic effects of tobacco

• cardiovascular diseases (#1 cause of death in US)

• pulmonary diseases (leading cause of COPD and over 80% of lung cancer deaths)

• main cause of oral cancer

• tobacco and use of other drugs

hallmark of nicotine addiction

• compulsive use

• use, despite its harmful effects

• pleasant (euphoric effects)

• difficulty with quitting or controlling use

• recurrent cravings

• tolerance

• physical dependence

  • relapse after abstinence

neurochemicals released by brain that reinforce effects of nicotine

• dopamine

• norepinephrine

• serotonin

• beta-endorphins

• vasopressin

reinforcing effects of nicotine

• chemicals produce effects in brain that cause user to experience pleasure, anxiety and tension reduction, a sense of well being, arousal, appetite suppression, and short term memory improvement

tolerance of nicotine

• results form neuroadaptation

physical dependence of nicotine

• when nicotine is not available, brain function becomes disturbed, which results in withdrawal symptoms

oral manifestations of tobacco and nicotine use

• vary with type of tobacco used and form in which it is used

• pattern and severity of clinical presentation vary with frequency and duration of use

• ENDS have shown oxidative stress and cell death to epithelium tissue

• extraoral/intraoral examination most efficient and effective method for detecting tobacco related conditions in and around mouth

pipe smokers

• may have nicotine stomatitis on palate

oral health effect of tobacco use

• oral mucosal lesions are typically white, hyperkeratinized, and wrinkled

• three to six times more likely than non smokers to develop periodontal disease

• changes should be described to patients as they might not be aware of oral effects of tobacco use

withdrawal

• duration

• alleviation of symptoms

• prevention of relapse

  • environmental cues like alcohol, coffee, and food may be triggering

    nicotine suppresses appetite so quitting also leads to gaining weight

    on average individuals who quite gain 10 pounds

psychologic aspects of quitting

• provides a sense of comfort, security, or entertainment

behavioral aspects

• relate to responses that tobacco users develop from having experiences various formas of gratification from tobacco use

sensory apsects

• oral gratification

sociocultural aspects

• peer pressure, family influence, social network

characteristics of patient centered communication

• collaborating ( not persuading)

• eliciting information (no imparting imformation)

• emphasizing the clients autonomy (not the authority of expert)

• open ended questions to elicit responses

treatment for tobacco dependenncy

• reasons for quitting: self-efficacy/ personal belief (what are their reasons for quitting, plan intervention specific to patient)

• self help interventions: on their own

• assisted strategies: counseling, medication

pharmacotherapies used for treatment of nicotine addiction

• zyban

• intended to help for cravings, contains slight amount of nicotine

• reduce with drawl syndromes and is much less addictive than tobacco products

• not recommended for those under 21

• dental professionals may educate patients on the use and options for dosage

dental hygiene care for patient who uses tobacco

• majority of smokers state they would like to quit

• specific treatment modifications indicated

• helping patients quit using tobacco becomes integral part of dental hygiene care plan

the five A approach

• ask

• advise

• assess readiness to quit ( are they ready)

• assist (how to go about)

• arrange (instructions and appointments for counseling)

clinical treatment procedures

• dental biofilm control

• stain

• calculus

• Nonsurgical periodontal therapy - healing is compromised in smokers

• other patient instruction

  • nutrition/diet ( big, patients are going to want to eat, suggest non-carogenic foods to stimulate such as carrots)

  • exercise

tobacco cessation program

• essential component of oral healthcare plan

• often requires multiple appointments, repeated interventions, and multiple attempts to quit

• dental setting provides excellent opportunity to assist in tobacco cessation

• interventions and outcomes will vary

• even minimal intervention may help a patient become tobacco free

ask

• health history

• present questions carefully

• obtain patients confidence (empathy and support of their choice to change, do not judge)

• children, adolescents, parents

advise

• always _ risks about use, but be empathetic and understanding

• commend never users/ former users

• current users: stop look listen approach

• show areas affect by use

assess

• ask if they are ready to quit

assist

• establish a quit plan

• provide practical counseling

• pharmacotherapy

• involve family and friends to give them encouragement

• provide educational information

  • “elicit, provide, elicit”

elicit provide elicit

• elicit- patients reasons to quit

• provide- education, resources, support a quit date

• elicit- “what would you like to do”

arrange

• follow- up

• contact the patient before the quit date

• provide additional resources and encouragement

advoacy

• community oral health education programs

• learn about tobacco legislation and public health policy

documentation

• history and/or current use, type of tobacco, and amount typically used

• age, ethnicity, gender, periodontal, and overall dental status and oral cancer screening findings

• interest/ confidence and motivation/readiness to quit and previous quit attempts and techniques used

• options or cessation presented to patient

factors to teach patient

• never start using tobacco

• how to perform regular self-examination of oral cavity (if anything is changing in size or color)

• pregnant women who use tobacco products can harm developing fetus and newborn infant

• educate parents to provide guidance in young children who may experiment with tobacco/ nicotine products

tobacco and periodontal infections (appearance in oral cavity)

• paler tissue color

• decreased bleeding due to vasoconstriction

• thickened/ fibrotic tissue

• reduced erythema vs extent of disease

• gingival recession

• increased bone loss, probing depths, CAL, and furcation

• response to treatment

diabetes mellitus

• a group of disorders characterized by hyperglycemia resulting from defective insulin secretion, defective insulin action, or combination of both

hyperglycemia

• abnormally high blood glucose, rise in blood glucose concentration

• prevention is the best treatment

• emergency treatment requires hospitalization

prediabetes

• is a condition that precedes type 2 diabetes

  • impaired glucose tolerance (IGT)

  • impaired fasting glucose (IFG)

type 1 diabetes mellitus

• insulin deficient (absolutely no insulin production)

• rarely obese- ketoacidosis

type 2 diabetes mellitus

• insulin resistant

• deficiency of insulin

• insulin secretion defect

gestational diabetes

• occurs during pregnancy

other specific types of diabetes mellitus classifications

• diabetes mellitus associated with certain conditions and syndromes

  • endocrine

  • pancreatic

  • genetic

ketoacidosis

• blood glucose levels rise to >400 mg/dL

cardinal signs of diabetes include

• polydipsia

• polyuria

• polyphagia

• unexplained weight loss

• weakness

• diabetic ketoacidosis (DKA) untreated can lead to death

polydipsia

• excessive thirst

polyphagia

• excessive ingestion of food

disease managment

• glycemic control

• insulin therapy

• lifestyle change

glycemic control

• self-monitoring of blood glucose and monitoring of HbA1c

clinical signs and symptoms of diabetes mellitus

• microvascular and macrovascular disorder

• diabetic retinopathy with potential vision loss

• nephropathy leading to renal failure

• peripheral neuropathy with risk of food ulcers, amputation, and neuropathic joint disease

• autonomic neuropathy causing gastrointestinal genitourinary and cardiovascular symptoms and sexual dysfunction

oral hypoglycemic (lowering) agents

• metformin: decreased glucose secretion

• sulfonylureas

• meglitinides

• thiazolidinedione

• dipeptidyl peptidase-5 inhibitors

• alpha-glucosidase inhibitors

injectable agents for type 2 diabetes

• exenatide

• amylinomimetics

dental hygiene process of care in patients with diabetes

• patients with well-controlled diabetes can be treated safely, as long as their daily routines are not affected

• infections of any type can cause a profound disturbance of glycemic control

• prevention of oral diseases and infections is critical to the patients diabetic control, and poor diabetic control may aggravate the oral disease status

assessment: health history

• question the patient regarding signs and symptoms of ketoacidosis to determine is an undiagnosed diabetic condition is present or if the patient is at high risk for diabetes

oral assessment for diabetics

• cheilosis

• xerostamia

• increased levels of cariogenic microorganisms

• glossodynia (burning mouth and tongue)

• enlarged salivary glands

• increased glucose in saliva

• fungal infections such as candidiasis

• dental caries

• periodontal disease

diagnosis and planning of diabetes

• care plan focuses on patients unmet human needs and allow the clinician to manage risks of potential diabetic emergencies

• scaling and periodontal debridement are contraindicated for people with uncontrolled diabetes

• care should not begin until diabetic condition is controlled

implementation

• removal of hard and soft deposits and bacterial toxins is critical

• avoid unnecessary tissue manipulation and trauma

• antimicrobial treatment, systemic doxycycline (20 mg twice daily)

• use vasoconstrictors with caution; minimal use

evaluation of periodontal tissue in patients with diabetes

• well-controlled diabetes respond positively to nonsurgical periodontal therapy

• delayed healing may indicate hyperglycemia

• recommend frequent oral assessments, periodontal maintenance, evaluation of response to dental hygiene care, and monitoring of diabetic control

documentation

• record all data collected, treatment planned and provided, and recommendations and other information relevant to patient care and treatment

hypoglycemia

• results from an excess of insulin and glucose deficiency in the body

• <70 mg/dl

blood glucose dismisal

• 230 blood sugar

• 9.0 or higher A1C

factors for diabetic patient care

• appoint patient 1.5 to 3 hours after taking insulin

• have glucose ready to administer in case of hypoglycemia

• do NOT keep patient waiting

• avoid stress

• decrease appointment time

• type 1 diabetes is more prone to ketoacidosis

A1C for patients without diabetes

• 4-5.6

target A1C for diabetic patients

• <7

normal blood sugar

<140 mg/dL

abnormal blood sugar

• reading of more than 200 mg/dl after two hours

edentulous

• being without teeth or lacking teeth

prosthesis

• a fixed or removable appliance that is functionally and cosmetically designed to replace a missing natural tooth or teeth

demographics

• approximately 1 in 5 adults 65 years or older in the United States and Canada is completely edentulous

risk factors for tooth loss

• dental caries

• periodontal diseases

• low socioeconomic status

• inadequate access to professional oral care

• low frequency of professional oral care

• poor daily oral hygiene

psychologic factors associated with tooth loss

• attitudes and values

• expected behavioral changes

physiologic factors

• residual ridge and alveolar bone resorption

• oral mucous membrane remodeling

• loss of orofacial muscle tone

hard and soft tissue changes in edentulous patients

• after tooth extraction, major bony changes, such as residual alveolar ridge resorption, occur within the first year and continue throughout life

• generally, older individuals resorb bone at a fast rate

exotoses

• benign bony outgrowth

obturator

• prosthesis that closes an opening or communication between nasal and oral cavity

components of fixed partial dentures

• abutment

• pontic

implant-supported overdentures

• removeable complete dentures designed to fit over implant fixtures that are inserted partially or entirely into living bone

factors affecting the oral mucosa of prostheses wearing individuals

• systemic diseases and conditions

• xerostamia (dry mouth)

• denture occlusion and fit

• oral hygiene

• continuous wear of dentures

denture stomatitis

• inflammation of the oral mucosa underlying the denture

• characterized by redness, pain, and swelling

papillary hyperplasia

• abnormal increase in the volume of tissues as a result of irritation

chronic candidiasis

• long standing C. albicans infection

reactive or traumatic lesions

• commonly secondary to either acute or chronic injury

• often painless

• surgical removal or irritating factor is an effective method of treatment

• palliative treatment can include over the counter products such as Rincinol and ameseal

mixed reactive and infectious lesions

• trauma and infection are causative factors contributing to mixed reactive and infectious lesions

• cobblestone appearance describes granular papillary projection that result from hyperplastic tissue response

• surgical removal, antifungal agents, soft tissue conditioners and liners, and strict oral hygiene measures are all options to remove lesions

denture stomatitis

• infectious lesion

• most common inflammation of removeable dental prosthesis- bearing mucosa

angular cheilitis

• infectious lesions

• mixed bacterial and fungal infection typically caused by staphylococcus aureus and c albicans

chronic candidiasis

• infectious lesion

• causes most removable dental prosthesis-related infections

importance of regular professional care

• need for assessment of oral tissues and maintenance

• irritation may be a co-carcinogenic factor in predisposed individuals

instrument sharpening objective

• to restore blade sharpness while preserving the original contours and angles of instrument

• improve patient comfort while decreasing clinician fatigue

• at first sign of instrument dullness, dental hygienist should sharpen instrument

Sharpening stones

• natural

• synthetic

• diamond sharpening cards

fine stones

• preferable for novice or for sharpening during patient treatment

coarsely surfaced stones

• remove metal at a faster rate than finely surfaced stones

rotary-mounted stones

• more abrasive than coarse handled stones

diamond sharpening cards

• are usually more costly than traditional oil and water stones

manual sharpening technique

• move the instrument over the stone (recommended especially for sharpening flat surfaces such as a sickle scaler)

• move the stone over the instrument (recommended for curettes)

mechanical sharpening techniques

• manufacturers offer honing devices and battery-operated sharpening devices that have built-in channel guides

explorer sharpening tehcniques

• two to three rotations around tip on stone sufficiently sharpens the instrument

universal curette sharpening techniques

• sharpen the two lateral sides, face, and toe on each end

• even pressure on all surfaces when sharpening, heel, middle, toe third

• visual or tactile testing for sharpness