Conditions Flashcards
- Hypertension
a. Things to ask about- ——-
b. Critical numbers: ———
c. Treatment: ———-
d. Recommendations for blood pressure: —–
e. Discussion of risks vs. benefits to dental surgery: —-
What is your typical and goal BP? Are you following the treatment recommendations of your PCP? Have you had any recent changes in medication, change in dosage, addition or deletion of medication? Have you had any complications? Are you able to climb two flights of stairs without having chest discomfort or shortness of breath?
Normal 120/<80; Elevated 120-129/<80; Stage 1 HTN 130-139/80-89; Stage 2 HTN 140+/90+
Weight loss, smoking cessation, control of blood glucose and lipids, moderation of alcohol, structured physical activity program
<160/100→no referral necessary, proceed with dental care; 160-179/100-110→ yes but with caution; consider BP monitoring, see PCP within 1 mo; <180/110→ defer elective treatment, asymptomatic: to PCP within 1 wk, symptomatic and/or diastolic >120: immediate evaluation
- Diabetes
a. Things to ask about-
A. How often to take A1c?
b. Well controlled diabetes A1c–
c. Dental concerns-
i. Acute odontogenic infection in diabetics-
ii. Extraction, I&D, antibiotics for DDS, MD→ ——
iii. Hypoglycemia secondary to too much insulin or too little food: ——
v. Prevention of insulin shock: ——
What type of diabetes do you have? How is the diabetes being treated? What medication? What was your most recent HbA1c reading? How often do you get it read? How often have you had a reaction to insulin? Have you been put on dialysis because of uncontrolled diabetes? Have you had any systemic complications because of your diabetes?
i. 2x/year reading if controlled
ii. 4x/year reading if uncontrolled
7.0 or less; Uncontrolled diabetes 8.0+
for well controlled: elective care is okay, check glucose prior to starting treatment; for uncontrolled: need to aggressively manage infection, avoid elective surgery, systemic risks include HTN, CAD, stroke
potentially significant problem, infection can lead to loss of diabetic control, loss of diabetic control can lead to aggressive infection, more concerned with uncontrolled and brittle diabetics and those type I diabetics on high insulin dosages
glycemic control
mild- hunger, weakness, sweating tachy; moderate- incoherent, uncooperative, belligerent, disorientation; severe- unconscious, hypotensive, tachy
iv. Treatment of insulin rxn: If conscious→ oral glucose within 5 min; if unconscious→ EMS, glucagon injection (IM), BLS prn
instruct patients to follow normal insulin regimen and eat normally around appointment, morning appointment, confirm that they ate and took insulin/hypoglycemic, instruct patient to notify you of symptoms during the office visit, source of sugar in the office
- Arrythmia
a. Things to ask about- ——-
b. Modifications to dental treatment: ——
c. Discussion of risks vs. benefits to dental surgery: —–
When were you diagnosed? How is it being treated? Have you had any ED/hospital visits? How often do you see a cardiologist for this condition? Have you had any recent symptoms?
Profound LA, limit epi, stress reduction, familiarity with implantable devices, drug interactions, post-procedure analgesia
Concerns about bleeding if anticoagulated with warfarin- what was your most recent INR? Local measures → achieve hemostasis
- COPD
a. Cause of COPD- —–
b. Main complications of COPD- —–
c. Medical management- ——
d. Things to ask about- ——
e. Things to notice: ——
f. Chair positioning- ——
g. Avoid which drugs- ——
smoking (usually)
progressive deterioration with periodic exacerbations, progressive dyspnea, recurrent pulmonary infections, pulmonary hypertension- right-sided heart failure, thoracic bullae & pneumothorax
smoking cessation, annual influenze and pneumococcal vaccinations, short and long-acting bronchodilators, anticholinergics, inhaled steroids for refractory cases, theophylline for severe cases, antibiotics prn, supplemental O2
How long have you had COPD? Have you had any emergency room visits? How is it being managed and have you had any recent symptoms?
shortness of breath at rest, productive cough, upper respiratory infection, reschedule elective treatment
upright or semi-supine, don’t do bilateral IAN or palatal blocks, nitrous oxide/oxygen is fine for mild-moderate COPD; avoid when there is severe COPD
anticholinergics/antihistamines; careful for narcotics (decreases respiratory drive)
Epilepsy
a. Things to ask about- —–
b. Key drugs- ——
c. Dental concerns- —–
When were you diagnosed? How has it been managed? Have you been compliant with treatment, has it been working? Have you ever experienced status epilepticus? Do you have an aura? What was the date of your last seizure? Are there any precipitating factors? If you think that you will have a seizure during dental treatment we will need you to bring an escort
phenytoin, carbamazepine, valproic acid
make sure that you continue anticonvulsant therapy, good stress/pain control, stop procedure immediately and remove everything from mouth, passively supper the patient to prevent injury, should have return of consciousness within few minutes, escort home
Anxiety
a. Medical treatment of anxiety disorders- —–
b. Key drugs- —–
c. Things to ask about- —–
d. Dental considerations- ——
i. Hyperventilation- —–
behavioral treatment, drug treatment, psychotherapy; maximum benefit→ behavioral therapy + drug therapy
SSRI’s Benzodiazepines
What type of anxiety disorder do you have? What is the current treatment for your anxiety? How do you feel it is working?
nitrous, consistent verbal and nonverbal communication, if they appear anxious, invite them to talk about it
move pt into upright position, reassure and talk with pt, breathe slowly with paper bad or into cupped hands over nose and mouth
Depression
a. Drugs- —–
b. Dental management- —–
c. Things to ask about- —–
SSRIs are first line
support the patient, drug interactions, all dentistry indicated
when were you diagnosed, how is it being managed? Do you feel the treatment is working well?
- Liver Cirrhosis
a. Needs a ——!!
b. Things to ask about- —–
i. Assess severity- —–
ii. If they have chronic hepatitis→ ——
c. Dental considerations- ——-
i. Dental drugs that may need dosage adjustment- —-
ii. May need —– for elective surgical cases
physician consult
cause of liver disease? Severity of liver dysfunction?
when were you diagnosed with liver disease, how is it being treated? Have you spent any time in the hospital because of your liver disease? What are your symptoms?
requires physician consultation
deficiency of vitamin K dependent coagulation factors leading to a predisposition to bleeding; can have increased, unexpected drug effects, acetaminophen can lead to severe/fatal hepatocellular disease
lidocaine, acetaminophen, ibuprofen, antibiotics
abx prophylaxis
- Alcoholism
a. Could have bone —— due to thrombocytopenia in addition to decrease in coagulation factors = increased bleeding; need to take pre-op —–need to have — microliters for minor oral surgery; may have increased infection risk
marrow suppression
platelet count (CBC)—
> 50k
- Osteoporosis
a. Drugs- —–
bisphosphonates, danger with extractions
Drug List:
• —- citalopram/celexa; escitalopram/Lexapro; fluoxetine/Prozac; paroxetine/paxil/pexeva; sertraline/Zoloft; vilazodone/viibryd
SSRIs-
• —— furosemide/Lasix; hydrochlorothiazide/microzide; spironolactone/aldactone; triamterene/dyrenium
Diuretics
- End stage renal disease/dialysis
a. Things to ask about- —–
i. Concerning symptoms of end stage renal disease- ——-
b. Dialysis done —- occasionally, but always when —
c. Do not take blood pressure on —–
d. Get physican consultation concerning nephrotoxic drugs and those excreted by kidneys if GFR
what was your last GFR? When were you diagnosed with renal disease? How is it being managed? Have you had any symptoms? Do you very easily bruise?
fatigue/weakness, easy bruising, bleeding, anemia, thirst/cramps, skin color changes, making little/no urine, dialysis
<30%, <15%
the dialysis arm
60%
do dental treatment after dialysis, avoid nephrotoxic drugs and those metabolized by the kidney
- Blood thinning medications
a. Drugs- —-
b. Platelet count- —- bleed excessively with minor trauma; —– spontaneous bleeding
c. Dental management- ——
d. Things to ask about- ——
i. Need to have a ——
ii. Newer oral anticoagulant drugs- —–
antiplatelet: clopidogrel, tirofiban
<50k, <20k
DO NOT discontinue the antiplatelet drugs, use local measures to control hemostasis
when were you diagnosed? Is your disease being managed? What was your most recent INR?
pre-operative INR (48hr); warfarin should not be discontinued INR <3.0 minor oral surger/invasive dentistry okay
not monitored with INR, typically you hold 1 preoperative dose and 1 postoperative dose, patients with renal impairment may need to hold more pre-operative doses
- Drug Addiction
a. What is the max MED? —–
b. Things to ask about- —–
c. Physician consultation- —-
d. Dental considerations- —–
e. National Helpline for drug addiction
30mg of MED
What type of drug addiction? What is the frequency of your drug abuse? When did you last use?
need to work with physician managing substance abuse program to manage pain
MI with epinephrine within 24 hrs of cocaine/methamphetamine use; no dental treatment with acute intoxication
