Chapter 1: The Medically Compromised Patient In The Dental Clinic Flashcards
The factors that define a medically compromised patient?
- High medical risk.
- Difficulty of management (in technique or behaviour).
- Oral lesions that are characterstic to the systemic disease.
- Interactions between the systemic disease and the dental treatment.
ASA I?
- healthy patient, good at tolerating stress.
- no modifications necessary.
- null or minimum anxiety.
- NON-SMOKER.
ASA II?
- mild systemic disease.
- healthy with maximum anxiety.
- adjust the treatment to their necessity.
- type I diabetes, epilepsy, asthma, advanced age, pregnancy, allergies, smoker.
ASA III?
- severe systemic disease, not disabling.
- minimise risk during treatment.
- angina pectoris of long evolution, stroke longer than 6 months ago, COPD, epilepsy or asthma badly controlled.
ASA IV?
- disabling disease.
- necessary modifications and treat in hospital.
- angina pectoris or recent stroke less than 6 month ago, severe arrhythmia, severe COPD, severe hypertension, uncontrolled diabetes, uncontrolled epilepsy.
ASA V?
- dying patient.
- palliative dental treatment.
- advanced cancer patients, terminal liver or kidney pathologies, infectious patients.
Side effects of NSAIDs?
GI damage.
Lower analgesic dose, higher anti-inflammatory dose, absorption with arginine speeds up its absorption? Which NSAID?
Ibuprofen
Dose of ibuprofen?
Adults: 400-600mg/ 8-12 hours.
Children: 5-10mg/kg/dose 6-8 hours.
Gold standard analgesic and antipyretic, doesn’t cause gastric irritation, but high doses cause hepatoxcity, not an inflammatory analgesic. Which NSAID?
Paracetamol
Doses of paracetamol?
Adults: 500mg-1gr/ 4-6 hours.
Children: 10-15mg/kg 4-6 hours.
Analgesic and antipyretic, but withdrawn due to onset of agranulocytosis?
Metamizole (dipyrone).
Doses of Metamizole?
500mg/ 6-8 hours
Which NSAID doesn’t interfere with anticoagulant levels, and is very gastro tasting?
Diclofenac
Doses of diclofenac?
50mg/ 8 hours (With food)
Risk factors in gastropathy for NSAIDs?
- over 60 years old.
- previous ulcerous history.
- high doses of NSAIDs.
- severe illnesses.
- treatment associated with anticoagulants.
- treatment associated with corticosteroids (at doses > 10md/day).
Side effects of NSAIDs?
- Alteration of renal function.
- Hepatotoxicity.
- Anti-platelet hemorrhagic complications.
- Forbidden in pregnancy.
- Emergence of allergic reaction.
- Reye syndrome in children with viral disease after intake of aspirin.
Associated with non-opioid analgesic, potentiates its effect, produces constipation. Which narcotic analgesic?
Codeine
Association of codeine?
500mg paracetamol, or 400-600mg ibuprofen.
Doses of codeine?
30mg/ 4-6 hours.
Dizziness and nausea. Which narcotic analgesic?
Tramadol adolonta-zaldiar
Association of tramadol?
37.5mg tramadol with 375mg paracetamol.
Doses of tramadol?
50-100mg/ 6-8 hours.
Which anti-inflammatory is NOT used with diabetics?
Glucocorticoids, because they increase glucose levels in the blood.
Glucocorticoids should be used:
- minimum dosage required for process control.
- during the shortest possible time.
- with the largest possible dose interval.
- with the fastest possible reduction.
Side effects of glucocorticoids?
- gastro toxicity.
- alteration of glucose metabolism.
- suppression of the hypothalamic-hypophyseal axis- adrenal.
What are glucocorticoids associated and prescribed with?
Antibiotics. To speed up healing and reduce the swelling and inflammation from an infection.
What are glucocorticoids used to treat?
Asthma, COPD, allergies.
The glucocorticoids with the highest anti-inflammatory potential are?
Dexamethasone (25).
Betamethasone (25-30).
Do ATB eradicate the infection or the pain?
No, they help by making it not spread. The immune system removes the infection.
ATB prophylaxis is given for?
2-3 days before, 5-7 days after the treatment.
Antibiotic prophylaxis is given to which patients?
- healthy patient.
- patient at risk.
- prophylaxis of bacterial endocarditis.
- prophylaxis ATB in patients with total joint prosthesis.
+ in hereditary hemorragial telangiectasia or Enf. From rendu osler weber.
Infection prevention of articular prosthesis?
- prosthesis < 2 years.
- history of infections.
- type I diabetes.
- malnutrition.
- haemophilia.
- systemic arthropathies (rheumatoid arthritis, lupus).
The penicillins ATB include?
- amoxicillin
- amoxicillin with clavulanic acid.
- ampicillin.
(-Cillin).
Same as beta lactam ATBs.
Penicillins are:
Wide spectrum and bactericidal.
The imidazole ATBs are?
- metronidazole (flagyl).
- metronidazole + spiramycin (rhodogil).
- (Azoles).
Imidazoles are ?
Bactericidal.
The macrolide ATBs are?
- erythromycin.
- clarithromycin.
- azithromycin.
(MYCINS: except clindamycin).
Macrolides are?
Bacteriostatic.
The tetracycline ATBs are?
- doxycycline.
- tetracycline.
(Cyclines).
Tetracyclines are?
Bacteriostatic.
The lincosamide ATBs?
Clindamycin
Lincosamides are?
Bacteriostatic+ bactericidal.
Doses of amoxicillin?
Clamoxyl
500mg, 750mg, 1gr.
Doses of amoxicillin and clavulanic acid?
Augmentine
500mg, 875mg, 1gr.
Doses of ampicillin?
Britapen
500mg, 1gr.
Doses of metronidazole?
Flagyl
250mg.
Doses of erythromycin?
Pantomycin
(500mg, 1gr).
Doses of clarithromycin?
Klacid, kofron
500mg
Doses of azithromycin?
Zithromax
500mg
Doses of doxycycline?
Solupen
100mg.
Doses of tetracycline?
Bristacycline dental
250mg.
Doses of clindamycin?
Dalacin
300mg, 600mg
Which ATB has excellent bone penetration?
Clindamycin
Which ATB has the broadest spectrum?
Carbapenems
ATB alter the intestinal flora and interfere with the absorption of?
Oral contraceptives
ATB interfere in the metabolism of?
Oral anticoagulants.
Which ATBs? Macrolides, clones, and metronidazole.
Macrolides should be avoided with?
Antihistamines
Avoid alcohol during and after treatment with ATB because of?
ETOH disulfram reaction
Doses of diazepam? And effects?
- 5 or 10mg the night before and one hour before the treatment.
- muscle relaxant and decreases anxiety.
Drug toxicity of LA appears?
After 30 mins.
You can get a toxic reaction from LA due to?
- Overdose
- Intravascular administration
Allergic reactions from LA appear after?
24-48 hours.
Lidocaine
Mepivacaine
Articaine
2%
3%
4%
Which LA is more potent and toxic than lidocaine?
Bupivacaine
Which LA comes without VC?
Mepivacaine
Which LA is more potent and less toxic than lidocaine but has a complication of methamoglobinemias?
Prilocaine
Vasoconstrictor:
- reduces anaesthetic absorption
- reduces overall toxicity
- produces hemostatic effect
Do NOT use VC in cases of?
- Hyperthyroid patient (tirotoxic crisis/ thyroid storm).
- Tricyclic antidepressants and MAOis (iproniazide).
- Any patient with a systemic disease uncontrolled (diabetes, HBP).
- Glaucoma.
- Doubts.
- A patient with acute myocardial infarction of more than 6 months, controlled hypertension, and type I diabetic without a sequel, is classified as?
A. ASA I
B. ASA II
C. ASA III
D. ASA IV
E. ASA V
C
In medically compromised patients we must avoid stress by?
A. Appointments in the late afternoon because they will be tired
B. Long appointments controlling treatments at all times
C. Avoid putting anaesthesia whenever possible
D. Do not premeditate if these patients have a high level of anxiety
E. Perform a good pre and post operative follow up
E
Patient with moderate renal insufficiency, with dialysis 3 days a week, hypertensive and is diabetic? What type of ASA?
IV
Which of the following factors does not increase the risk of gastropathy for NSAIDs?
A. Over 60 years old of age
B. Arterial hypertension
C. Previous ulcerous history
D. Treatment associated to corticoids
E. Elevated doses of NSAIDs
B
In all of the types of special patients mentioned below, in which can i use anaesthesia with vasoconstrictor?
A. Hypertensive and hyperparathyroid patients
B. Hypothyroidism
C. Type I DM
D. Type II diabetes and hypertensive
E. In all of them
E
54 year old patient with hepatitis C, in treatment with anticoagulants, and has a stomach ulcer. What type of ASA?
ASA III
A 56 year old patient who has moderate renal insufficiency (GFR reduced to 30%) and has started dialysis 3 times a week, has hypertension (enalapril), and is a non-insulin dependent diabetic. What type of ASA?
III
30-50% GFR: slight, no symptoms.
In the analgesic treatment of dental pain. It’s false that:
A. Prescription of an ATB may be indicated
B. Dental pain is always caused by an infectious process inside or around a piece
C. Local cold is an effective measure in postoperative pain
D. Diazepam can reduce pain by relieving muscle tightness
E. The association of analgesics with NSAIDs potentiates the analgesic action
Wrong question, A and B are right.
A 24-year-old patient who presents inflammation, cervical lymphadenopathy and has had a fever. He is a smoker patient with congenital ischemic heart disease. Drugs he takes, digoxin ® (antiarrhythmic), Nifedipine
® (antihypertensive), Tertensif ® (diuretic). and an annual drug for the bones. What type of ASA ?
ASA III
Which of the following antibiotics is the first choice for the treatment of oral conditions in a patient allergic to penicillin?
A. Metronidazole
B. Azithromycin
C. Clindamycin
D. Ciprofloxacin
E. Tetracycline
B
In the analgesic treatment of dental pain, it is false that:
a. In anxious patients, it is advisable to evaluate the association of a benzodiazepine
b. Prescription of an antibiotic may be
indicated
c. Antiepileptic drugs have no indication in the treatment of pain
d. Local cold is an effective measure in
postoperative pain
e. Diazepam can reduce pain due to relieving muscle contracture.
B
Which of the following statements is correct?
a. Dental treatments in patients with epilepsy should be performed in the hospital setting
b. Vomiting and diarrhea after taking a drug are specific symptoms of an allergic reaction
c. When in doubt of a possible allergy to a local anesthetic it is advisable to request the evaluation of an allergist
d. Prescription of analgesics or antibiotics does not alter the levels of an antiepileptic or anticoagulant medication
e. If a patient does not take medication on a regular basis we can be sure that he does not have a major illness
A,b,or c?
With regard to the usual medication that a patient who comes to a consultation takes, it is true that:
a. It is a useful indicator for the identification of chronic diseases
b. When prescribing an NSAID, it should be taken into account if the patient is coagulated
c. The taking of several drugs for arterial hypertension usually indicates a difficult control of the same
d. Diabetic patients who require control of their disease to take oral antidiabetics and insulin are more likely to have hypoglycaemia
e. All are true
E
The antibiotic prophylaxis of choice will not depend on:
a.Type of acute process presented by the patient
b. Clinical manifestations that the patient has
c. Presence of infection in the tooth
d. Existence of systemic pathologies
e. Treatment to be performed
C
What type of ASA would be a patient who does not have any systemic pathology, Is allergic to penicillins and smoker of 20 cigaretts a day?
a. ASA O
b. ASA I
c. ASA HI
d. Non-cataloged petient
e. ASA II
E
Indicate which of the following factors doesn’t define a patient as medically compromised:
a. Patient that because of its conditions, changes and difficults the management of the patient at the consult
b. Patient with high medical risk
c. A patient in which its systemic pathology interferes with the dental treatment
d. Patient that presents dental alterations on the oral mucosa because of a systemic disease and need specific treatment
e. Patient that presents oral lesions originated at the oral mucosa
E
For the direct and efficient control of the pain of a patient with infectious dental pathology, we can prescribe the following medications:
A. Ibuprofen at high doses 1200mg/ 8hrs
B. Clindamycin 300mg/6hrs
C. Dexketoprofeno (Enantym) 25mg/8hrs
D. Diclofenac at double te dosage as its the less gastrolesive
E. Paracetamol at low dosage to avoid its gastrolesive
C
Indicate the correct statement regarding the general considerations about antibiotic therapy:
a. Antibiotics correctly used, completely eradicate the infection without having to do any further treatments
b. Erythromycin cant be associated with antihistamines and it doesn’t interfere with the
metabolism of any medication, specially anticoagulants
c. Metronizadol decreases the risk of hemorrhage as it interferes with anticoagulants, it will be the antibiotic of election in patients taking anticoagulants
d. Antibiotics can alter the intestinal absorption of the estrogens in the oral contraceptives, making them less effective
e. Alcohol must be avoided from three days before starting the antibiotic treatment
D
Indicate the correct statement regarding steroidal anti-inflammatories (corticoids) in dental treatment?
A. It doesnt have any anti inflammatory potential
B. We must use the highest dose as possible at all times, it has no contraindications
C. It depresses the immune system of the body, so we must adjust the dose to the minimum, for the shortest time possible and gradually reducing the dose
D. Corticoids must only be used in cases of gastric problems, as we will not use NSAIDs in these cases
E. To avoid any complications with this medication, dentist must only use it intravenous
C
A patient with poorly controlled asthma and without sequelae belongs to ASA group?
A. ASA I
B. ASA II
C. ASA III
D. ASA IV
E. ASA V
C
Point out the false answer regarding the side effects of NSAIDs?
A. Encephalopathies and metabolic disorders in children with previous viral disease
B. Shortens pregnancy and labor
C. Hepatotoxicity
D. Decrease platelet aggregation causing hemorrhages
E. They can alter glomerular kidney function
B
Patient with uncontrolled hypertension is classified as ASA?
IV
