8B. Clinical Considerations

Question 1

Feeding and Eating Disorders

Take a look at the chart!

Answer 1

yes

Question 2

Feeding and Eating Disorders

• On the dental examination, the finding of a pattern of tooth ____ that is consistent with habitual ____ may be the first indication of the presence of an eating disorder.
• It is important to address the improper ____ (dental caries) and the effects of chronic ____ on the teeth (erosion).

Answer 2

erosion
regurgitation
diet
vomiting

Question 3

Feeding and Eating Disorders
• In patients with bulimia, complex restorative procedures should ____ be planned until the gorging and vomiting cycle has been broken.
• In a few cases, crowns may be required in an attempt to save teeth. When the patient’s overall health status is ____, restoration of teeth with severe erosion can begin.

Answer 3

not

stable

Question 4

Mental Disorders

Substance related and addictive disorders
• The effects of street drugs, such as methamphetamines, cocaine, and ecstasy, have all been well documented in the dental literature.
• They can cause devastating consequences to the ____, periodontium, and oral mucosa, as well as a heightened potential for ____ and dentofacial injury.

Answer 4

teeth

trauma

Question 5

Neurologic Considerations
• Neurologic diseases are common in the general population, and they will become even more common as the population ages.
• Patients with neurologic disease require ____ management considerations depending on the extent of impairment.
• It is important to not only understand the pathophysiology of the disease itself, but to understand how the long term management and treatment of these conditions will impact their care.

Answer 5

individualized

Question 6

Neurologic Considerations

Take a look at the table!

Answer 6

yes

Question 7

Neurologic Considerations
• Patients with neurologic diseases are at high risk during dental treatment for complications such as ____, myocardial infarction, adverse ____, altered consciousness, and infection.
• It is important to work closely with their physicians to develop dental management plans that will be effective and safe.

Answer 7

stroke

bleeding

Question 8

Cerebrovascular Accident
• Stroke is a generic term that is used to refer to a cerebrovascular accident (CVA): a neurologic event caused by sudden interruption of ____ blood to the brain.
• The associated ischemic injury results in focal ____ of brain tissue, which may be fatal.
• Even if a stroke is not fatal, the survivor often is debilitated in ____ function, speech, or cognition to a certain degree.

Answer 8

oxygenated
necrosis
motor

Question 9

Cerebrovascular Accident
• ____ is the leading cause of serious, long-term disability in the United States.
• Stroke is the fifth leading cause of death in the United States, with more than 130,000 Americans dying of stroke annually.
• 5% of the population older than 65 years of age has had at least one stroke.

Answer 9

stroke

Question 10

Cerebrovascular Accident
• ____ stroke accounts for 85% of all strokes in the
United States (embolic). 15% are ____.
• ____ is the most important risk factor for ischemic and hemorrhagic stroke.
• ____ carries a 3% to 5% annual risk for stroke.
• 7-10% of people >65 have ____ stenosis of greater than 50% which carries a 2% annual risk for stroke.

Answer 10

ischemic
hemorrhagic
hypertension
atrial fibrillation
asymptomatic carotid artery

Question 11

Cerebrovascular Accident
• The risk for stroke in smokers is almost ____ that in nonsmokers, but the risk becomes essentially ____ to that in nonsmokers 2 to 5 years after quitting.
• The relative risk for stroke is two to six times greater for patients with ____.
• Compared with Caucasians, ____ are at 38% greater risk for a stroke with a similar greater risk of death.
• An average dental office will have about 31 patients who have had, or will experience a stroke.

Answer 11

double
identical
type 1 diabetes
AA

Question 12

Cerebrovascular Accident

Clinical considerations
• ____ should be involved in stroke prevention. Patients with hypertension, congestive heart failure, diabetes mellitus, previous stroke or TIA, and advancing age are predisposed to stroke, as well as to ____.
• Assess patient risk, encourage persons with risk factors to seek medical care, and eliminate or control all possible risk factors.

Answer 12

dentists

MI

Question 13

Cerebrovascular Accident

Timing for treatment
• Up to one third of strokes recur within ____ month of the initial event, and risk remains elevated for at least ____ months.
• Deferral of ____ is advised for 6 months after TIA or stroke.
• Although risk decreases after 6 months, it continues to be ____; 14% of those who survive a stroke or TIA have a recurrence within ____ year.

Answer 13

1
6
treatment
present
1

Question 14

Cerebrovascular Accident

Bleeding risk
• Patient management after a stroke depends on the cause. For example, patients who sustained an ischemic stroke will frequently be managed with ____ or antiplatelet medications.
• Patients with atrial fibrillation may be considered for ____ vs. antiplatelet medications (CHADS2 score).

Answer 14

anticoagulants

anticoagulation

Question 15

Cerebrovascular Accident

Bleeding risk
• The data is clear: post-CVA patients in whom the usual anticoagulant regimen is ____ before undergoing dental treatment are at risk for adverse events.
• Therefore, it is advisable to not ____ the anticoagulant regimen unless consultation with the physician permits it.
• To reiterate: do not ____ antiplatelet or anticoagulation medications on your own. There really isn’t a need for it anyway.

Answer 15

altered
adjust
alter

Question 16

Cerebrovascular Accident

Bleeding risk
• Warfarin: works by blocking ____, and inhibits clotting factors ____, Protein C, and Protein S.
• Warfarin is monitored by the lab test ____.
• Most conditions are managed with INR from ____. Mechanical heart valves are the exception with recommended values of ____ (rarely higher).

Answer 16

vitamin K epoxide reductase
II, VII, IX, X
INR
2-3
2.5-3.5

Question 17

Cerebrovascular Accident

Bleeding risk
• An INR level of 4 or less is ____ for performance of most dental and oral surgical procedures.
• If the INR is greater than 4 and oral surgery is planned, the physician should be consulted regarding a ____ in dosage of the anticoagulant.
• In such cases, a ____ in dose of the anticoagulant is recommended over ____ of anticoagulation therapy because the risk for significant adverse outcomes is minimized by this approach.

Answer 17

acceptable
decrease
reduction
interruption

Question 18

Cerebrovascular Accident

Bleeding risk
• This approach can be translated to the newer anticoagulants such as ____ (Rivaroxaban, apixaban and edoxaban) but further studies are needed and there are concerns regarding lab tests and reversals.
• Generally, intraoral bleeding can be controlled with local ____ measures, even with patients on ____ or therapeutic anticoagulation medications.

Answer 18

Xa inhibitors
hemostatic
antiplatelet

Question 19

Cerebrovascular Accident

Visit considerations
• Management of patients with a history of stroke includes the use of ____, ____ appointments that are free of stress and anxiety.
• ____ may help. Limit ____.
• Depending on the condition of the patient, dental care providers should move ____ around the patient and should speak clearly, with the mask off, while facing the patient.

Answer 19

short
midmorning
nitrous oxide-oxygen
epinephrine
slowly

Question 20

Parkinson’s Disease

• Parkinson’s disease is a progressive neurodegenerative disorder of neurons that produce ____.
• Loss of these neurons results in characteristic motor disturbances - ____, muscular control and rigidity, movement, bradykinesia, and postural instability.
• This disease is ____ and progressive, and there is no ____.

Answer 20

dopamine
resting tremor
chronic
cure

Question 21

Parkinson’s Disease
• Parkinson’s disease is the second most common neurodegenerative disorder after ____ disease.
• It occurs in over 2% of persons older than 65 years and 5% in persons older than 85 years.
• An average dental practice is predicted to include about 4 patients who have Parkinson’s disease.

Answer 21

alzheimers

Question 22

Parkinson’s Disease
• A major manifestation of Parkinson disease is ____ (that is ____ during activity), muscle rigidity, ____ movement (bradykinesia, shuffling gait), and facial impassiveness (mask of Parkinson disease).
• The tremor is ____ and fine and is best seen in the extremity at rest (____).
• Cogwheel-type rigidity, ____ posture, unsteadiness, and imbalance are common

Answer 22

resting tremor
attenuated
slow
rhythmic
pill-rolling
stooped

Question 23

Parkinson’s Disease
• ____ impairment of memory and concentration occurs to a variable degree.
• Mood disturbances (depression, dysthymia, apathy, anxiety), insomnia, and fatigue occur in approximately 40% of patients.
• ____ occurs in approximately 25%.
• Psychosis, related to dopaminergic ____,
occurs in approximately 20% of patient

Answer 23

cognitive
dementia
medications

Question 24

Parkinson’s Disease

Treatment
• The goal of therapy is to increase ____ levels in the brain.
• No optimal ____ treatment is available and each person is treated on an individual basis.

Answer 24

dopamine

drug

Question 25

Parkinson’s Disease
• Because the tremor can contribute to poor oral hygiene, the patient’s ability to cleanse their dentition should be ____.
• For patients unable to provide adequate home care, alternative solutions should be provided, such as the introduction of the ____ toothbrush, mechanical toothbrushes, assisted ____, or chlorhexidine rinses.

Answer 25

evaluated
collis curve
brushing

Question 26

Parkinson’s Disease
• If the patient is experiencing xerostomia - ____ and poor denture ____ are likely to result.
• ____ substitutes are beneficial in alleviating symptoms.
• Topical ____ should be considered for use in dentate patients.
• Personal care providers should be educated about their role in assisting and maintaining the oral hygiene of these patients.

Answer 26

dysphagia
retention
salivary
fluoride

Question 27

Parkinson’s Disease
• Orthostatic hypotension is an adverse effect associated with ____.
• To reduce the likelihood of a fall from the dental chair, the patient should be ____ to and from the chair. At the end of the appointment, the chair should be inclined slowly to allow for re- equilibration.
• The treatment plan for the patient with Parkinson disease may require ____ based on the patient’s ability to cleanse the oral cavity.

Answer 27

COMT inhibitors
assisted
modification

Question 28

Parkinson’s Disease
• Patients should receive dental care during the time of day at which their medication has maximum effect (generally, ____ hours after taking it).
• The presence of tremors or choreiform movements may warrant use of soft arm ____ or ____ procedures.

Answer 28

2-3
restraints
sedation

Question 29

Dementia and Alzheimer’s Disease

Overview
• Dementia is a term that describes a group of symptoms affecting ____, thinking, and social abilities severely enough to interfere with daily life.
• Alzheimer’s disease (AD) is an ____ progressive neurodegenerative condition and the most common form of ____, accounting for up to 80% of all cases.
• It is characterized by a progressive decline in ____ abilities with loss of higher cortical functions, such as memory, judgment, and abstract thought and is ultimately fatal.

Answer 29

memory
irreversible
dementia
cognitive

Question 30

Dementia and Alzheimer’s Disease
Overview
• Other causes of dementia include vascular dementia, and dementia caused by Parkinson disease, hepatic ____, acid–base and ____ disturbances, hypoglycemia, head trauma, ____ disease, uremia, primary or metastatic brain lesions, acquired immunodeficiency syndrome, trauma, syphilis, MS, stroke, and drugs.

• A small subset of dementias, such as ____ disease, may have a very rapid onset with a clinical course of less than 1 year.

Answer 30

encephalopathy
thyroid
electrolyte
creutzfeld-jakob

Question 31

Dementia and Alzheimer’s Disease

Overview
• Among persons older than 65 years of age, the prevalence is about 7%. From age 70 years on, the prevalence ____ every 5 years. By age 85 years, more than 40% of persons will have developed Alzheimer’s disease.
• An average dental practice includes about ____ patients with Alzheimer’s disease (PD was 4).

Answer 31

double

20

Question 32

Dementia and Alzheimer’s Disease

Overview
• The cause of Alzheimer disease is unknown but appears to involve the loss of ____ neurons and is characterized by ____ plaques and neuroinflammation that results in ____.
• There is no ____ and management remains difficult.
• Standard medications used in the treatment of mild to moderate disease have been the ____.

Answer 32

cholinergic
beta-amyloid
neurofibrillary tangles
cure
cholinesterase inhibitors

Question 33

Dementia and Alzheimer’s Disease

Dental considerations
• Dental management requires knowledge of the stage of disease, medications taken, and the cognitive abilities of the patient.
• Patients with mild to moderate disease generally maintain ____ systemic organ function and can receive ____ dental treatment.
• As the disease progresses, antipsychotics, antidepressants, and anxiolytics frequently are used and can contribute to ____ and dental caries.

Answer 33

normal
routine
xerostomia

Question 34

Dementia and Alzheimer’s Disease

Dental considerations
• Patients may not have an interest in ____ for themselves, and they may lack the ability to do so.
• Patients with Alzheimer disease have a greater incidence of ____ mouth, mucosal lesions, candidiasis, plaque and calculus ____, periodontal disease, and caries, along with an increased risk for ____.

Answer 34

caring
dry
buildup
aspiration pneumonia

Question 35

Dementia and Alzheimer’s Disease

Dental considerations
• Patients are best managed with an understanding and empathetic approach.
• The dental team should communicate a ____, hopeful attitude regarding maintenance of the patient’s oral health to both the patient and family members.
• The dental team should determine whether the patient is ____ able to make rational decisions. This issue should be discussed with the patient and family.

Answer 35

positive

legally

Question 36

Dementia and Alzheimer’s Disease

Dental considerations
• The dentist should communicate using ____ words and sentences and should ____ instructions and explanations.
• Nonverbal communication can be very helpful. Facial motion and body posture should show support.
• ____ nonverbal communication includes direct eye contact, smiling, touching the patient on the arm, etc.

Answer 36

short
repeat
positive

Question 37

Dementia and Alzheimer’s Disease

Dental considerations
• Patients with Alzheimer disease should be placed on an aggressive ____ dentistry program, including ____-month recall, oral examination, prophylaxis, fluoride gel application, oral hygiene education, and adjustment of ____.

Answer 37

preventive
3
prostheses

Question 38

Dementia and Alzheimer’s Disease

Dental considerations
• Patients with advanced dementia often are ____, hostile, and uncooperative in the dental office and very difficult to treat.
• These patients are best served with ____ appointments and noncomplex procedures; use of ____ may be required for more complex procedures.
• ____ and ____ can be used to provide the level of sedation required for performance of routine dental procedures.

Answer 38

anxious
short
sedation
NO
benzos

Question 39

Epilepsy
• Epilepsy is a term that refers to a group of disorders characterized by chronic and recurrent, paroxysmal changes in neurologic function (____), altered consciousness, or involuntary movements caused by abnormal and spontaneous ____ activity in the brain.
• Seizures may be ____ (motor manifestations) or may occur with other changes in ____ function (sensory, cognitive, and emotional).

Answer 39

seizures
electrical
convulsive
neurologic

Question 40

Epilepsy
• Seizures are produced by excessive neuronal discharging, which may result from ____ or ____ causes.
• Approximately 10% of the population will have at least ____ seizure in their lifetimes, and 2% to 4% will experience recurrent seizures at some point.
• In a typical dental practice, 3 or 4 can be expected to have a seizure disorder.

Answer 40

intracranial
extracranial
one

Question 41

Epilepsy
• Seizures can be evoked by specific stimuli.
• Approximately 1 of 15 patients reports that seizures occurred after exposure to ____ lights, monotonous sounds, music, or a loud noise.
• It is valuable to know what factors have the potential to exacerbate a seizure, so that certain stimuli can be avoided.

Answer 41

flickering

Question 42

Epilepsy
• A serious acute complication of epilepsy is the occurrence of repeated seizures over a short time without a recovery period, called ____.
• This condition most frequently is caused by abrupt withdrawal of ____ medication but may be triggered by ____, neoplasm, or trauma.
• Status epilepticus constitutes a medical ____. Patients may become ____ and ____ during this event and sustain ____ brain damage or death.

Answer 42

status epilepticus
anticonvulsant
infection
emergency
hypoxic
acidotic
permanent

Question 43

Epilepsy
• The medical management of epilepsy usually is based on ____-term drug therapy.
• ____ (Dilantin), carbamazepine (Tegretol), and ____ are considered first-line agents for treatment of this disease.
• Several other drugs are available for control of generalized ____ seizures.

Answer 43

phenytoin
valproic
tonic-clonic

Question 44

Epilepsy
• •
• For a patient with epilepsy, the dental practitioner must learn as much as possible about the seizure history, including the type of seizures, age at onset, cause, current and regular use of medications, frequency of physician visits, quality of seizure control, frequency of seizures, date of last seizure, and any known ____ factors.
• Fortunately, most patients with epilepsy are able to attain good control of their seizures with ____ drugs and are able to receive ____ dental care.

Answer 44

precipitating
anticonvulsant
routine

Question 45

Epilepsy
• Patients who take anticonvulsants may suffer from medication side effects.
• Because ____ is associated with phenytoin, these patients should maintain optimal oral hygiene.
• This may require frequent visits for monitoring of progress.
• If gingival overgrowth is significant, ____ reduction will be necessary.

Answer 45

gingival overgrowth

surgical

Question 46

Epilepsy
• A missing ____ or teeth should be replaced if possible to prevent the tongue from being caught in the edentulous space during a seizure.
• Generally, a ____ prosthesis or ____ is preferable to a removable one.
• For fixed prostheses, ____ units should be considered when possible to minimize the chance of fracture.

Answer 46

tooth
fixed
implant
all-metal

Question 47

Epilepsy
• When placing anterior castings, the dentist may wish to consider using ____ crowns or retentive ____ facings.
• Removable prostheses are nevertheless sometimes constructed for patients with epilepsy. ____ palates and bases are preferable to all-acrylic ones. If acrylic is used, it should be reinforced with ____.

Answer 47

three-quarter
nonporcelain
metallic
wire mesh

Question 48

Epilepsy
• Despite preventive measures, generalized ____ seizures can occur in the dental office.
• If a patient has a seizure while in the dental chair, the primary task of management is to ____ the patient and try to ____ injury.

Answer 48

tonic-clonic
protect
prevent

Question 49

Epilepsy
• No attempt should be made to ____ the patient.
• The instruments should be ____ from the area, and the chair should be placed in a ____ position.
• The patient’s ____ will be maintained patent.
• No attempt should be made to ____ or hold down the
patient.
• ____ restraint should be used only to prevent injury that may result when the patient hits nearby objects or falls out of the chair.

Answer 49

move
cleared
supine
airway
restrain
passive

Question 50

Epilepsy
• Trying to insert a ____ is not advised during a seizure because it may damage the patient’s teeth or create an aspiration risk.
• A grand mal seizure generally does not last longer than a few ____.
• Afterward, the patient may experience an altered state of consciousness (____) where they may be unresponsive or disoriented.
• ____, maintenance of a patent ____, and mouth ____ should be provided.

Answer 50

mouth prop
minutes
postictal state
oxygen
airway
suction

Question 51

Epilepsy
• Within a few minutes, the patient gradually regains ____ but may be confused, disoriented, and embarrassed.
• ____ is a prominent feature during this period.
• If the patient does not respond within a few minutes, the seizure may be associated with a low serum ____ level or other metabolic disturbance, the practitioner should evaluate for and treat if possible.

Answer 51

consciousness
headache
glucose

Question 52

Epilepsy
• In the event that a seizure becomes prolonged (____) or is repeated, ____ (0.05–0.1 mg/ kg) 4 to 8 mg,or 10 mg of ____, generally is effective in controlling it.
• ____ and ____ support should be provided because respiratory function may become depressed.
• If the seizure lasts longer than 15 minutes, the following protocol should be implemented: secure ____, repeat ____ dosing, administer ____, and activate the ____ system.

Answer 52

status epilepticus
IV lorazepam
diazepam
oxygen
respiratory
IV access
lorazepam
fosphenytoin
EMS

Question 53

Multiple Sclerosis
• Multiple sclerosis (MS) is characterized by chronic and continuous ____ of the corticospinal tract neurons.
• MS typically manifests in ____ adults with episodic neurologic dysfunction. The ____ nervous system is not affected.
• MS is second only to ____ as the leading cause of neurologic disability in young adults.
• It’s prevalence is about 1 case per 1000 persons.

Answer 53

demyelination
young
peripheral
head trauma

Question 54

Multiple Sclerosis
Overview
• The incidence of MS has been ____ beginning in the past century.
• The disease typically manifests between the ages of 15 to 50 years and affects ____ twice as often as men.
• Its prevalence is highest in the ____ regions of the world and it is infrequently seen along the Equator.
• A typical dental practice can expect to have about 3 patients in whom this condition has been diagnosed

Answer 54

increasing
women
temperate

Question 55

MS

• The cause of MS remains unknown; however, it is widely held that the disease is triggered by an ____ agent (possibly HH-6) in combination with ____ factors and other ____ factors.
• Four categories have been used to describe the course of the disease: ____ (occurs in 85% of patients), primary progressive, ____, and progressive-relapsing.

Answer 55

infectious
genetic
environmental

relapsing-remitting
secondary progressive

Question 56

Multiple Sclerosis
• Patients with relapsing forms of MS are given antiinflammatory medications in the form of ____ for acute attacks or ____(Avonex) or ____ (Betaseron) injections.
• Some of the newer biologic agents, such as ____, ustekinumab, and rituximab, have shown promise in treating MS.

Answer 56

IV corticosteroids
interferon b-1a
interferon b-1b
natalizumab

Question 57

Multiple Sclerosis
• Many complications of MS require management with several drugs. Spasticity is managed with antispastic drugs such as ____, benzodiazepines, ____, and tizanidine.
• Poor bladder control is managed with anticholinergics such as ____.
• ____ inhibitors and tricyclic antidepressants are used to manage the depression that accompanies MS in about half the patients.

Answer 57

baclofen
dantrolene
oxybutynin
serotonin

Question 58

Multiple Sclerosis
• The dentist can play an important role in directing the patient with clinical findings suggestive of MS.
• Reports of abnormal facial pain (mimicking ____), numbness of an extremity, visual disturbance, or muscle ____ may suggest a new diagnosis.
• The disease should be suspected if onset is progressive over several days, the patient is between 20 and 35 years of age, and afternoon ____ is a feature.
• A brain ____ and rerral to a neurologist is the next step in confirming the diagnosis.

Answer 58

trigeminal neuralgia
weakness

fatigue
MRI

Question 59

Multiple Sclerosis
• Oral manifestations may serve as the presenting symptoms of MS.
• The most common features include ____, paresthesia, numbness of the orofacial structures, and ____.
• Dysarthria produces slow, ____ speech with unusual separation of syllables of words, referred to as ____ speech.
• missing bullet: A brain ____ and referral to a neurologist is the next step in confirming the diagnosis

Answer 59

dysarthria
trigeminal neuralgia
irregular
scanning
MRI

Question 60

Multiple Sclerosis
• Patients experiencing a relapse should not receive ____ dental care. Emergency dental care can be provided but will be affected by their ____.
• The optimal time for treating patients with MS is during periods of ____.
• The dental care plan should take into consideration the potential effects on oral health of the medications used in management of MS.
• In particular, the anticholinergics and TCAs can cause a ____, which may respond to salivary substitutes.

Answer 60

routine
medications
remission
dry mouth

Question 61

Multiple Sclerosis
• Treatment planning changes are dictated by levels of motor ____ and fatigue.
• Patients with stable disease and little motor spasticity or weakness can receive ____ dental care.
• Patients with more advanced disease may require help in maintaining oral hygiene, and may be poor candidates for reconstructive and prosthetic procedures.
• Because fatigue is often worse in the afternoon, ____ appointments are advised.

Answer 61

impairment
routine
short morning

Question 62

Multiple Sclerosis
•
• During an attack, the patient may experience facial ____, and muscles of facial expression (especially the ____) can ____ in a wavelike motion.
• ____ is 400 times more likely among persons with MS than among the general population. Relief of trigeminal neuralgia pain can be obtained with the use of ____, clonazepam, or ____ or surgery.

Answer 62

paresthesia
periorbital
undulate
trigeminal neuralgia
carbamazepine
amitriptyline