1 Flashcards
What is the key to successful dental management of a medically compromised patient
a thorough evaluation and assessment of risk
What is Dr. Munk’s recommended technique to obtain a medical history
a questionnaire, followed by an interview
What are some of the concerns you must consider when treating a patient who has had cancer
Radiation can destroy salivary glands and lead to Xerostomia
Radiation can also lead to Osteonecrosis following treatment
How does radiation lead to Osteonecrosis following treatment
it destroys rapidly growing cells, which include vascular endothelial cells. this leads to destruction of the blood vessels, which can lead to inadequate supply of necessary nutrients to repair bone following an operation.
What is a patient’s functional capacity
the ability of the patient to engage in normal, everyday activities
what is used to express a person’s functional capactiy
metabolic equivalent levels (MET)
What is the MET score that shows an increased risk of a serious postoperative event (MI, heart failure)
< 4 MET
What are some activities that require ~ 4 METs
level walking at 4 miles/hour
climbing a flight of stairs
What are some activities that require 4-7 METs
bicycling
golfing without cart
gardening
What are some activities that require > 7 METs
playing squash
jogging
singles tennis
scrubbing floors
What types of things do you look at when evaluating a patient’s general appearance
skin, nails, face, eyes, nose, ears, neck
What does an HbA1C tell you about someones blood glucose
it gives you their glycogenated hemoglobin levels (an indication of their average blood glucose levels over the last 120 days)
What is an HbA1c of 6 in terms of blood glucose levels (approximately)
125
What is an HbA1c of 8 in terms of blood glucose levels (approximately)
185
what is an HbA1c of 7 in terms of blood glucose levels (approximately)
155
what is an HbA1c of 10 in terms of blood glucose levels (approximately)
245
what is an HbA1c of 9 in terms of blood glucose levels (approximately)
215
what is an HbA1c of 11 in terms of blood glucose levels (approximately)
275
what is an HbA1c of 12 in terms of blood glucose levels (approximately)
305
What are the four components of evaluation of risk assessment
- nature, severity, and stability of patients medical condition
- the functional capacity of the patient
- the emotional status of the patient
- the type and magnitude of the planned procedure
What are the 4 tools we use to evaluate a patient and make a risk assessment
- medical history
- physical examination
- lab tests as needed
- medical consultation as needed
What does an INR test tell you
it tells you how much a patient’s blood has been thinned by their medications
what do you expect the INR of a healthy individual to be
1
what is the target INR for a patient with a mechanical heart valve
3
what is the target INR for a patient with atrial fibrillaition
2
what is the INR at which we won’t treat a patient, and should do a medical consult
> 4 (their is a high risk of uncontrolled bleeding)
As a dentist are we comfortable treating a patient with an INR between 2 and 3
Yes
What does an INR of 5 indicate about the patient
that they will have uncontrolled bleeding with trauma
how recently do we want our patient INR to be taken before treating
quite recently, an INR that is a month old is probably longer than we would prefer.
What is the normal range of a white blood cell count
4,400 - 11,000/mL
What is the normal range of a red blood cell count in men
4.5 - 5.9 10^6/uL
what is the normal range of a red blood cell count in women
4.5 - 5.1 10^6/uL
What is the normal range of a platelet count
150,000 - 450,000/uL
What is the normal range for a hematocrit in men
41.5% - 50.4%
what is the normal range for a hematocrit in women
35.9% - 44.6%
what is the normal range of a hemoglobin count in men
13.5 - 17.5 g/dL
what is the normal range of a hemoglobin count in women
12.3 - 15.3 g/dL
what is the normal range for fasting glucose
70-110 mg/dL
what is the normal range for Blood urea nitrogen
8-23 mg/dL
what is the normal range for Creatinine
0.6 - 1.2 mg/dL
what is the normal range for Bilirubin indirect (uncongugated)
0.1 - 1.0 mg/dL
what is the normal range for Bilirubin direct (congugated)
<0.3 mg/dL
what is the normal range for Calcium, total
9.2 - 11 mg/dL
what is the normal range for Magnesium
1.8 - 3.0 mg/dL
what is the normal range for phosphorus, inorganic
2.3 - 4.7 mg/dL
what is the normal range for sodium
136 - 142 mEq/L
what is the normal range for potassium
3.8 - 5.0 mEq/L
what is the normal range for chloride
95 - 103 mEq/L
what is the normal range for bicarbonate
21 - 28 mmol/L
Is it ok to get a medical consultation via phone call
yes, it may be quicker and easier (but it doesn’t provide a written statement for the patient’s record)
order the following medical consultation types from most likely to get a response to least
- disease specific or focused questionnaire
- Check all of the boxes questionnaire
- Formal letter
What is infective endocarditis
a microbial infection (usually bacterial but can from other microorganisms) that attacks the endothelium of the heart and heart valves.
does infective endocarditis usually occur in proximity to other heart defects.
yes, they can allow blood in the heart to become stagnant in certain parts of the heart which allows the microbials to infect the endocardium
What has been the emphasis toward infective endocarditis since it has a significant mortality rate
prevention by administering antibiotics prophylactically
how effective has the use of prophylactic antibiotics been in preventing infective endocarditis
its effect has never been substantiated and the evidence questions the validity of this practice
Why is bacteremia (which leads to infective endocarditis) such a concern for dentists
because basically every dental procedure can lead to bacteremia (some do quite frequently)
according to the current AHA recommendations, are you more likely to get infective endocarditis from bacteremia caused by a dental procedure, or bacteremia associated with daily activities
much more likely to get infective endocarditis from bacteremia associated with daily activities than from dental procedures
according to the current AHA recommendations, does prophylaxis prevent cases of infective endocarditis for patients undergoing a dental procedure
it may prevent few if any, and the risks of adverse-antibiotic events exceeds any potential benefit of prophylactic therapy
according to the current AHA recommendations, what is most effective at preventing cases if infective endocarditis
maintenance of optimal oral health and hygeine
is prophylactic use of antibiotics recommended for patients with joint replacements
no
what are the four cardiac conditions for which antibiotic prophylaxis is recommended to reduce the risk of infective endocarditis
- prosthetic cardiac valve
- previous infective endocarditis
- congenital heart diseases (those that are unrepaired, recently repaired (last 6 months), and those that weren’t completely successfully repaired)
- cardiac transplantation recipients who develop cardiac valvulopathy
what dental treatments require prophylactic use of antibiotics when the patient has 1 of those 4 cardiac conditions that require prophylactic antibiotics.
any treatment that manipulates the gingival tissue, periapical region of the tooth, or perforates the oral mucosa (not including routine anesthetic injections)
what is the first drug of choice when prescribing a prophylactic antibiotic and what is the dose in adults and children
amoxicillin
2 g - adults
50 mg/kg - children
what drug would you prescribe as a prophylactic antibiotic when a patient is allergic to penicillins and what is the dose for adults and children
clindamycin
600 mg - adults
20 mg/kg - children
cephalexin
2 g - adults
50 mg/kg - children
azithromycin/clarithromycin
500 mg - adults
15 mg/kg - children
what drug would you prescribe as a prophylactic antibiotic if a patient is unable to take oral medication. and what are the doses for adults and children?
ampicillin (IM or IV)
2 g - adults
50 mg/kg - children
cefazolin/ceftriaxone (IM or IV)
1 g - adults
50 mg/kg - children
what drug would you prescribe as a prophylactic antibiotic if a patient is allergic to penicillins and can’t take oral medications. and what are the doses in adults and children?
cefazolin/ceftriaxone (IM or IV)
1 g - adults
50 mg/kg - children
clindamycin (IM or IV)
600 mg - adults
20 mg/kg - children
what drug would you prescribe as a prophylactic antibiotic to a patient who is currently taking penicillin or amoxicillin and why?
clindamycin, azithromycin, or clarithromycin because they likely have bacteria that are resistant to penicillin/amoxicillin.
(you could also wait until the patient has been off of the antibiotic for 10 days, then proceed as per usual)
What is the blood pressure at which a patient is considered to have hypertension
140/90
what is considered “normal” blood pressure
120/80
what blood pressure is considered prehypertensive
120-139 / 80-89
what blood pressure is considered stage 2 hypertension
> 160/>100
(stage 1 hypertension 140-159/90-99
what is the pulse pressure and how is it calculated
it is the difference between the systolic and diastolic pressure
you calculate it by subtracting the diastolic pressure from the systolic
How is Mean Arterial Pressure (MAP) calculate
you take the diastolic pressure and add 1/3 of the pulse pressure
what is considered the normal pulse pressure
40
at what value does the pulse pressure indicate an increased risk for cardiovascular disease
> 60
what is considered the normal MAP
70-110
at what value does the MAP indicate an increased risk for cardiovascular disease
> 110
What is the primary concern when treating a patient with hypertension
the patient might experience an acute elevation in blood pressure resulting in MI or stroke
what are the three questions we should ask ourselves when considering whether or not to treat a patient with hypertension
- what is the risk if the patient is treated
- what is the risk if the patient is untreated
- at what level of blood pressure it is unsafe to continue
What are the treatment recommendations for a patient with hypertension
< 160/100 = any treatment required
> 160/100 but <180/110 = treat with caution, consider intraoperative monitoring of bp
>180/110 = defer elective treatment
what is the maximum dose of Epinephrine that can be used in a patient with heart disease
40 mcg
what is the maximum dose of Epinephrine that can be used in a healthy patient
200 mcg
What is ischemic heart disease
atherosclerosis = thickening of the internal layer of the arterial wall caused by the accumulation of lipid plaques which results in narrowed arterial lumen and decreased blood flow. this can lead to MI, coronary heart disease, stroke and peripheral arterial disease
how should a patient with stable angina or previous MI be managed
- short morning appointments
- monitor vitals
- confortable chair
- nitroglycerin ready
- stress reducing measures
- limited vasocontrictor use
- adequate post-operative pain control
at what heart rate is considered tachycardia
> 120 bpm
at what heart rate is considered bradycardia
<50 bpm
how are cardiac arrhythmias treated
- antiarrhythmic medication
- anticoagulation therapy
- implanted permanent pacemakers
- implanted cardioverter-defibrillator
what is our primary concern with patient who are susceptible to arrhythmias
stress associated with dental treatment, or excessive epinephrine can lead to life threatening arrhythmias
What is chronic obstructive pulmonary disease (COPD)
general term for pulmonary disorders with chronic airflow limitation from the lungs that isn’t fully reversable
what are the most common diseases associated with COPD
emphysema
chronic bronchitis
what is chronic bronchitis
excessive tracheobronchial mucus production causing a chronic cough
what is emphysema
distention of the air spaces due to destruction of the alveolar walls = gas exchange isn’t sufficient
what is the most significant cause of COPD
cigarette smoking
what are the signs of a patient with chronic bronchitis
lots of sputum production sedentary and overweight cyanotic edematous breathless (blue bloaters)
what are the signs of a patient with emphysema
exertional dyspnea minimal non-productive cough barrel chested weight loss (pink puffers)
how do we manage a patient with COPD
encourage the patient to quit smoking
avoid treating when patient has UR infection
treat in upright position
use pulseoximeter
may use oxygen (nitrous is contraindicated)
consider supplemental steroids
do patients with adrenal insufficiencies need supplemental glucocorticoids when undergoing routine dental treatments
No, the vast majority of them do not
what patients are at risk for adrenal crisis
those undergoing stressful surgical procedures and have no, or exteremely low, adrenal gland function
do patients who are currently taking corticosteroids need supplemental steroids?
no, they generally have enough endogenous and exogenous cortisol to handle the procedure as long as they took them within 2 hours of the surgery
(especially not if they are undergoing minor procedures)
what steroid supplementation should be done for a patient taking <7.5 mg of prednisone and undergoing a minor procedure
supplementation usually isn’t necessary
what steroid supplementation should be done for a patient taking >7.5 mg of prednisone and undergoing a minor procedure
the patient should double their dose the morning of treatment
what steroid supplementation should be done for a patient taking steroids and undergoing a procedure causing moderate surgical stress
10-15 mg prednisone for 1-2 days before the surgery, then taper back to normal following the procedure
What is asthma
chronic inflammatory airway disease associated with airway hyperresponsiveness, dyspnea, coughing, and wheezing
How should an asthmatic patient be managed
identify type, trigger, frequency, andseverity of asthma
avoid triggers
have patients inhaler present
evaluate need for aspirin, NSAIDs, narcotics
consider steroid supplementation
stress reduction protocol
what is tuberculosis
a disease caused by mycobacterium tuberculosis that spreads via inhalation of infected droplets, and is characterized by “tubercles” that develop in affected tissues
what medications are taken for tuberculosis
Isonaizid
rifampin
pyrazinamide
how do we manage treating someone who has active tuberculosis
only urgent care is done and if a handpiece is needed it is only done in a hospital setting to prevent spreading of the infected droplets
what is obstructive sleep apnea
a disorder in which the airway becomes obstructed typically due to a narrowing upper airway combined with a collapsable pharyngeal dilator muscle
how is obstructive sleep apnea treated
c-PAP (positive airway pressure) during sleep
mandibular advancement devices
tongue retaining devices
surgical interventions
