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BS VI, Module II > 4. HB Oral/Dental Considerations > Flashcards

4. HB Oral/Dental Considerations Flashcards

1
Q

Occupational Exposure

• Dentists use a lot of ____. Needles to inject patients with LA, trigger point injections into jaw muscles, inject lesions with corticosteroids to heal faster… Lots of uses for sharps.
• Don’t want to stick ourselves or put the patient at occupational exposure risk as well
• Deal with a lot of fluid from oral cavity: blood, saliva, things that can transport/harbor infectious
organisms that pose a risk to us and other patients. Have to be mindful of splashes to open sores and other mucous membranes

• Dentists use a lot of dental instruments that are ____
◦Student once dropped a perio scaler on her toe and got cut and infected.
◦D3s tend to lose awareness of clinical surroundings, accidentally stick themselves when
moving quickly and not paying attention. Can drop instruments or back up on a burr. ◦Have to maintain composure and maintain awareness to avoid unintentional occupational
exposures

A

sharps

sharps

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2
Q

Viral transmission in the dental setting

  • Transmission of virus
  • ____
  • Most likely method of transmission
  • DHCP to the patient
  • Patient to patient
  • Exposure to virus
  • ____ injury
  • Needle stick
  • Cut with sharp instrument

• Contact of ____ tissues, blood, bodily fluids with mucous membranes or non-intact skin

A

patient to dental health care personnel

percutaneous
infectious

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3
Q

Risk of HBV occupational transmission

  • Acute or chronic HBV infection
  • Transmit virus if ____ (+)
  • If ____ (+), risk of infx increases 10- fold than HBsAg (+) only
  • Risk after a needlestick injury
  • 3-6% if HBsAg (+) carrier
  • 30% if HBeAg (+) carrier
  • HBsAg detectable in ____
  • Dentistry is considered one of the health care professions with the highest risk of ____ exposure
  • Infection rates 3-10x higher than general population
  • Prior to mandatory HBV vaccination for dentists
  • Prevalence of HBV serologic markers ranged 16 -28%
A

HBsAg
HBeAg
saliva
HBV

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4
Q 
Risk of HCV occupational transmission
• Prevalence of infection to health care workers is \_\_\_\_% • Similar to that of general population
• 1/10th of risk of \_\_\_\_ transmission
• HCV is detectable in \_\_\_\_
• Case reports of transmission
• 2 cases of \_\_\_\_ splash to conjuctiva
• 1 case of HCV / HIV transmission after non – intact \_\_\_\_ exposure 
• 1 case of \_\_\_\_ HCV transmission
A 
1-2
HBV
saliva
blood
skin
patient-to-patient
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5
Q

Dental occupational exposure
• Total elimination of risk is not ____
• Minimized with standard ____ and ____

A

achievable
precautions
vaccination

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6
Q

• Use ____, gloves, eye ____ (for provider and patient), hair coverings.
• Use needle caps and protectors to prevent sticks. Use cardboard protectors
• ____. Use of sterilization equipment is imperative to maintaining appropriate infection
control

A

gowns
protection
autoclaving

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7
Q

DHCP Vaccination
• DHCP who perform tasks involving contact with infectious materials must be vaccinated against ____
• Tested ____ months after 3-dose series
• Check for anti-HBsAg
• May receive 2nd 3-dose series if antibody titers are ____
• Vaccine-induced antibodies ____ over time
• 60% will lose detectable antibodies over 12 years

A

HBV
1-2
inadequate
decline

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8
Q

Exposure management
• Exposure management protocols
• SDM
• Private practice

  • Basic principles
  • Prompt ____
  • Access to post-exposure ____ and care
  • Ensure ____ for DHCP and source patient

• Specific protocol and policies in all schools and private practices. Need to have a record of exposure management bc if a health inspector comes and takes a look, need to have it ready
◦Lots of inspection in the school from ____ and other state officials. May get random state inspection in practices too. They always look for exposure management protocol!
◦Also good to have it just for normal office protocol policies

A

reporting
testing
confidentiality

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9
Q

• After exposure, obtain ____ to test source patient for HBsAg, anti-HCV and HIV

• Hepatitis B
• Treatment with Hep B ____ and / or ____ according to
protocols

  • Hepatitis C
  • No post-exposure medications ____
  • Follow-up ____ evaluations
A 
consent
vaccine
HBIG
recommended
laboratory
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10
Q

Detection of liver disease
____ and physical exam ____ signs / symptoms
____ signs / symptoms

A

history
general
oral

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11
Q 
Oral manifestations of liver disease
• \_\_\_\_ changes
• Hemorrhagic changes • Petechiae
• Hematoma
• Gingival bleeding
• \_\_\_\_ gland enlargement
• Glossitis
• \_\_\_\_
• Sjogren’s like syndrome • Lichen planus
A

mucosal
parotid
hepatitis C

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12
Q

Patient with yellow gingival tissue. End stage liver disease with jaundiced gingiva. Not common.
• Patient with hyperbilirubinemia and gingival tissues are affected. Hyperbilirubinemia can be be
seen ____!

A

intraorally

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13
Q
  • Patient with hemorrhagic perioral lesion that can be seen in a patient with end stage liver disease.
  • Larger varicosities that may ____ bleed. Can be hard to control this hemorrhage. They may need to be sclerosed or addressed in other ways
  • Perioral region has a very vascular look to it
A

spontaneously

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14
Q
  • Patient has gingival bleeding even though their gingival tissue looks good. No evidence of edema, mo visible plaque, nice stippling.
  • Healthy gingiva, but ____ profusely. Cannot control gingival hemorrhage.
  • This is not caused by local factors, caused by a ____ bleeding/clotting disorder related to liver disease.
  • Good example of healthy gingiva with significant bleeding. Systemic disorder is the source of oral hemorrhage
A

bleeding

systemic

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15
Q
  • Patient presents with parotid gland swelling (another manifestation of liver disease)
  • Parotid gland is very enlarged. If you palpated it, it would be ____
  • Looking intraorally, it would be difficult to milk the parotid gland and get ____ to come out of the parotid duct.

• This can be a recurrent issue. When patients have parotid gland swelling, it increases the risk of them developing ____ (parotid salivary gland infection.

  • Dentists would have to manage this by putting them on ____, help them massage the gland to maintain the patency of the gland and the duct
  • May be seen in emergency clinic or in hospital dental clinic.
A

tender
saliva
parotitis
antibiotics

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16
Q
  • Glossitis: This does not look like benign migratory glossitis (alternating red/white patterns). This is a true ____ with areas of erythema.
  • This may be attributed to an atrophic ____, a type of yeast infection that doesn’t have white cheesy plaque formation, more erythematous. This presentation could also be Fe or ____ deficiency or some type of anemia.

• Other possible causes, but this is also seen in liver disease!
• When patients present with things like this, rule out the local factors and then think about the
systemic causes for the oral sequelae.

A

de-papillation
candidiasis
B12

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17
Q
  • Different presentations of ____. The most common mucosal disease you will encounter in the general patient population
  • Left pic: typical ____ pattern. Wickhams striae, minimal erythema or ulceration. patients might not know they have it, might just not a textural change. Their cheek might feel rough, but there is no pain.
  • Symptoms range from asymptomatic to severe pain (in erosive or ulcerative form)
  • Right pic: ____ form. Extensive tongue ulcerations, pseudomembranes forming in different places. Significant pain and difficulty eating. This could have a huge impact on daily life
  • Oral LP can run the spectrum in terms of clinical presentation and symptomolgy.
  • Consider this when thinking of Hep C
A

lichen planus
reticular
ulcerative

18
Q

Dental Management
• Impaired ____
• Impaired ____ metabolism

◦Patients may have impaired hemostasis ability. Difficulty clotting can cause excessive
bleeding
◦Impaired drug metabolism. Lots of drugs are metabolized in the liver, if it is not functioning
properly, may not be able to metabolize things appropriately which can cause big issues

A

hemostasis

drug

19
Q 
Pre-treatment evaluation
• Medical \_\_\_\_
• Labs
• \_\_\_\_ with differential 
• \_\_\_\_ function tests
• \_\_\_\_ studies
• Determine need for pre – op \_\_\_\_ products
• Determine proper \_\_\_\_ for indicated dental treatment

Rarely in general out patient setting will a physician recommend a patient getting clotting factor or platelts as an infusion before dental treatment. Usually these types of patients are treated in a ____ dental clinic or an operating room dentistry setting. Physician will let you know if they need a platelet transfusion before major oral surgery (probs not routine dental treatment.

Most patients, if they are stable, can be treated in an out-patient setting (like the school or private practice). If patients have unstable liver disease, they might have to be treated in a dental hospital clinic or an OR dentistry setting.

A 
consultation
CBC
liver
coagulation
blood
venue
20
Q

Drug Metabolism
• Acetaminophen
• Use with caution
• Avoid > ____gm / 24 hour

  • ASA / NSAIDS
  • Generally ____
  • Aggravate ____
  • Renal complications

• Avoid narcotics
• May precipitate hepatic
____

  • Tramadol
  • ____ mg q12h
  • Antibiotics
  • Avoid ____, tetracycline, ____ and metronidazole
A 
2
contraindicated
bleeding
encephalopathy
50
clindamycin
doxycycline
21
Q
  • ____ is acceptable in patients with severe liver disease
  • Up to ____ carpules of 2% Xylocaine with 1:100K Epi
  • IAN block may pose risk of ____ in patients with blood dyscrasias
  • Consider diminished doses of hepatically-metabolized drugs when
  • ALT / AST > ____X normal
  • Bilirubin > ____ um/l
  • Albumin < ____ g/l
  • ____, encephalopathy, malnutrition are present
A 
3
hematoma
4
35
35
ascites
22
Q

Dental Management of the Liver Transplant Patient
• Pre-Transplant Dental Considerations

  • Post-Transplant Dental Considerations
  • ____ post-transplant period
  • ____ post-transplant period
  • ____ rejection period
A

immediate
stable
chronic

23
Q

Dental Treatment Considerations Pre-transplantation considerations

  • Significantly ill patient with ____-organ damage
  • Medical ____ required
  • Consider postponing ____ treatment
  • Dental consultation prior to anticipated transplantation
  • Evaluate for acute and chronic dental sources of ____
  • Stabilize current ____ status
  • Potentially remove sources of ____ that may lead to acute complications within the transplant process and immediate post-transplant period
A 
end
consultation
elective
infection
oral
infection
24
Q
  • Prior to administering treatment, consult with transplant ____ to determine medical risk vs. benefit of proposed dental treatment
  • Obtain laboratory information/supplemental ____ as needed: CBC with differential, aPT, aPTT, INR, metabolic panel, liver function tests, other organ-specific panels
  • Specific management issues as needed per individual case
A

physician

information

25
Q

Dental Treatment Considerations Post-transplantation considerations

  • Immediately after transplant
  • No ____ dental treatment performed
  • ____ treatment only with medical consultation
  • Stable period after functioning transplant
  • Elective treatment may be performed after medical ____
  • Assess level of ____
  • Assess for oral mucosal disease
  • Assess for ____
  • Assess for need for supplemental corticosteroids
  • Consider antibiotic ____ if neutropenic
  • Consideration of specific management needs
  • Chronic rejection period
  • ____ dental treatment only
A 
elective
emergency
consultation
immunosuppression
xerostomia
prophylaxis
emergency
26
Q

Oral considerations
• Gingival overgrowth
• ____
• Tacrolimus

  • Oral ulcers
  • ____
  • Sirolimus
  • ____
  • Infections
  • ____
  • Viral
  • ____
  • Increased risk of malignancies (long-term)
  • ____
  • Lymphoma
A

cyclosporin
mycophenolate mofetil
neutropenia

bacterial
fungal
SCC

27
Q
  • Classic case of gingival overgrowth.
  • Poor oral hygiene
  • Fibrotic and enlarged gingival tissue around poorly maintained teeth.
  • Seen with ____ and ____
A

cyclosporine

tacrilomus

28
Q
  • Left image: Large, aphthous-like ulcer on dorsal tongue. Edematous and inflamed around borders of lesions. Symmetrical in shape. Nice pseudomembrane covering ulcer bed. Classic presentation of an ____ or ulcer related to medication.
  • Neutropenic ulcers typically do not have ____ around the borders of the lesions. Surrounding tissue looks completely normal because of low neutrophils, body cannot mount a typical inflammatory response, cannot have a typical inflammatory appearance.
A

aphtous ulcer

inflammation

29
Q
  • This patient was taking mycophenolate mofetil after a liver transplant. She was admitted to the hospital because of mouth ulcers. Team called oral med. Stoopler thought the lesion might be caused by the meds, so he talked to transplant team and tried to convince them to change her immunosuppressant, but they just told him to do a biopsy. He didn’t want to biopsy bc she is medically complex and it could cause ____. Transplant physician took her off the Cellcept. Discharged the patient and told her to come back later. If it was still there, he would have done a biopsy.
  • She came back a few weeks later, and the lesion was gone (right pic). Tongue was totally healed and the lesion was gone. No biopsy was needed, they were able to establish that the medication was the reason she developed an oral ulcer.
  • Dramatic example of things we need to look at. We need to be comfortable in our knowledge base because physicians don’t always know. We have to advocate for our patients. If they had biopsied, could have caused a lot of bleeding and healing problems for the patients. No intervention was needed to treat her.
A

hemorrhage

30
Q

Bacterial Infections

• Pts on ____ have altered responses to typical things.
• Pt has a periodontal infection, but hard to tell on clinical exam only. Area doesn’t look that
inflamed, nothing draining out of area, not much swelling.
• Pt has a dental infection secondary to bacteria

A

immunosuppressants

31
Q

Viral Infection

  • Varying degree of viral infection. The most common are ____ and ____ infections.
  • Patients can present with ulcers (patient has HSV infection on ventral tongue)
A

HSV1

HSV2

32
Q

Recurrent Herpes Labialis

  • Patient has a very subtle recurrent ____(recurrent fever blister). This is another infection that might be ____.
  • This lesion might not be that easily detectable, but is is there
A

herpes labialis

prominent

33
Q

Recurrent Intraoral HSV

• Patient with intraoral HSV.
• Lesion has different clinical appearance to the tongue lesion of the patient on Cellcept. That
lesion was pretty symmetrical, aphthous-like
• This lesion has no distinct ____ to it.

  • When you suspect HSV infection, you do testing. Do an HSV ____ to identify HSV1 or HSV2 DNA. We can do this in the hospital setting
  • Patient test came back positive for HSV1
A

shape

PCR

34
Q

Recurrent orofacial HSV

• This is the same patient who had the above tongue lesion.
• These lesions can be ____. They can be life-threatening, especially in immunosuppressed
patient.
• Disseminated herpes infections could cause ____. These are things we have to be mindful of

A

extensive

death

35
Q

Fungal Infections

  • Typical oral pseudomembranous candidiasis infection
  • White/yellow cheesy ____ that can be ____ off to reveal an erythematous base.
A

plaques

rubbed

36
Q

Fungal Infections

• More of a deep fungal infection
• Immunosuppressed patients may develop weird things like
◦____ is the most common systemic fungal infection that can be in the oral cavity. Oral presentations may be the first sign

Lesion looks pretty nondescript, could be a lot of things. Could be a dental infection. Treat with ____. If it doesn’t go away, do a biopsy which could help you diagnose a fungal infection

  • Lesions in the maxilla have a tendency to spread to the ____ bone, sinuses, perforate nasal bones. People can get deep fungal infections when they are ____ (whether it is liver disease, status post-kidney transplant or whatever).
  • Deep fungal infections can be very misleading and difficult to diagnose
A

aspergillosis
antibiotics
maxillary
immunosuppressed

37
Q

Lymphoma

• Unremarkable ulcer. Central ulcerated bed with a halo around it. Some apthous appearance.
• Lesion did not go away or get smaller when treated with topical steroids.
• Did biopsy in patient that was status post liver transplant. Lesion was a lymphoma.
• When things don’t respond to typical treatment, you have to do more investigation. Knowing
that these patients are at higher risk for ____ and SCC, you have to be aggressive to make sure you are not dealing with one of those (they have life-altering consequences)

A

lymphoma

38
Q

Intraoral SCCa

  • Examples of SCC. Things that look ____.
  • Could be a mucosal disease, lichen planus, pemphigus, mucous membrane pemphigoid, etc.
  • Pt was a 90yo woman who had a liver transplant a long time ago
  • Ulcerated lesion had been seen by a lot of professionals.
  • It was treated with all sorts of topical and systemic steroids, but it didn’t go away
  • Biopsy showed that it is moderate to poorly-differentiated ____
  • Never would have guessed that looking at the lesion, they can be very deceptive
A

benign

SCC

39
Q

• Pt with large mass in alveolar mandibular ridge surrounding several teeth.
• Some professionals manage these lesions with antibiotics for weeks to months before
referring or biopsy. Even though this does not look like a typical infection.
• It has a mixed red and white appearance, no phenotypic architecture… This is cancer. Oral
cancer has a distinctive smell too…

  • This lesion was managed by a periodontist for 8 months with antibiotics and peridex.
  • Stoopler got a biopsy to confirm cancer diagnosis. Then pt needed workup by ENT and stuff.
  • Very large ____
A

SCC

40
Q

• •
Pt referred by healthcare provider for white lesion on cheeks, not the large lesion on her tongue. Lesion was impairing her speech. She has had it for 2 years. Healthcare provided did not biopsy the lesion. Doctor recommended coffee enemas to get rid of the toxins in her body so the lesion would shrink and go away.

Pt didn’t even want to get a biopsy. She finally signed the consent for the biopsy
Results came back as invasive ____. Lesion is huge, goes all the way to the floor of her mouth. Centimeters in size, indurated, hard…
This is what can happen when you see patients in the general population

A

SCC

41
Q

Biliary disease

  • Enamel ____
  • Delayed tooth eruption
  • ____ teeth
  • Deposition of ____ in dentin during tooth formation
  • Association of PBC and Sjogren’s syndrome?
  • Exfoliative ____ as presenting sign of gallbladder cancer
  • ____ =/= cholelithiasis
  • Green teeth due to deposition of bilirubin in dentin during tooth formation in kids with biliary disease.
  • There is some data to support the association of PBC with ____ syndrome (but not a lot)
  • Exfoliative dermatitis of perioral or facial skin
  • Cholelithiasis: ____ that form in the gallbladder or get stuck in the bile duct. There is no correlation with these and ____ stones. No association between those two types of stone formation
A 
hypoplasia
green
bilirubin
dermatitis
sialolithiasis

sjogren’s
stones
salivary

42
Q

• Article gives recommendations as to what kinds of antibiotics to administer for prophylaxis.
• Article states that it is not an official recommendation, but since the article is in ____, readers
may go to this as a resource when they have patients that need to be evaluated.
• Doctors might read this and just follow the directions to give antibiotic prophylaxis
◦Stoopler has a problem with this because there is no ____ to support this. So he reached out to the journal.

PAPERS AREN’T ALWAYS RIGHT

A

print

evidence

BS VI, Module II (4 decks)

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