Diseases of Human Systems Flashcards
1
Q
what does childhood health surveillance involve
A
- childhood screening
- immunisations
- universal health promoting activities such as childsmile
- early intervention to adress needs
2
Q
screening function
A
- check milestones
- check vaccination
- deliver health promotion and health&safety
- target supervision and intervention to risk groups
- in dentistry brought in for checkups even if healthy is an example of screening
3
Q
screening at school entry
A
- evaluated by teacher etc
- personal social and emotional development
- physical development
- communication skills
- hearing and vision assessment
4
Q
developing milestones
1 month and 2 months
A
- 1 month: raise head when on stomach, moves arms and legs energetically
- 2 months: smiles and coos, rolls part way to side when on back
5
Q
developing milestones
3 and 4 months
A
- 3: eyes follow moving object, grasp objects
- 4: recognises faces, sit supported for short periods of time
6
Q
developing milestones
6 months
A
- turn over from back to stomach
- turn towards sound
- reaches for objects and brings to mouth
- sucks, bites, begins chewing
7
Q
developing milestones
9 months
A
- stand for short time
- says mama or dada
- responds to name
- copies sound
8
Q
developing milestones
12 months
A
- can walk with one hand held
- enjoys some solid foods
- finger feeds self
- waves bye bye
9
Q
when does a child approx walk by self/stops creeping
A
- 15 months
- creeping is pulling body with arms and leg kicks
10
Q
developing milestones
year 3/4/5
A
- at this point improvement depends on stimulation they recieve
- varies per child
- jumping
- copy a circle
- dresses self
- stand on one foot
- catch ball
11
Q
purpose of childhood vaccination
A
- prevent certain infectious diseases where the risk of disease greater than risk of vaccination
- achieve herd immunity which can reduce or eliminate diseases from community
12
Q
recent changes to vaccinations
A
- polio vaccine is now innactivated compared to previous oral polio vaccine…decreases possibility of polio like symptoms from vaccine
- meningitis vaccines
13
Q
vaccines given to children under 1 year
A
- DTa/tetanus/polio/hepB
- menB
- rotavirus
- PCV
*
14
Q
vaccines given to children 1-3 years
A
- influenza live attenuated
- MMR
- MenB booster
- PCV
15
Q
vaccines given to teens
A
- HPV
- tetanus, diptheria and polio
- MenACWY
16
Q
why may parents refuse childhood immunisation
A
- religious or philosophical grounds
- prevent a “painful assult” on the child
- benefits dont outweigh risks
17
Q
What is epilepsy and what is it caused by
A
Epilepsy is a group of conditions in the brain due to abnormal discharge of neurons within brain
Associated with reduced GABA levels in brain (inhibitory NT)
Takes less stimulation for a neuron to fire message onto another cell
18
Q
What condition has the same symptoms as someone having chronic epilepsy
A
Febrile seizures
19
Q
Signs and symptoms of a febrile symptoms
A
Fever
Face may turn blue or red
Eyes rolling upwards
Loss of consciousness
Muscles and limbs jerk in unnatural movements
20
Q
Who gets febrile seizures and why
What are they prone to
A
Largely happens in children
Only happens when a child has a fever over 38 degrees
If it happens once it’s likely to happen again but does not mean they are epileptic just they are prone to febrile seizures
21
Q
Febrile seizures prevention
A
Cool children at risk of seizure who have a fever
Aintipiretic medication such as paracetamol and ibuprofen
Remove clothing for air cooling
Cooling sponge/bath
22
Q
Epilepsy classification
A
Generalised or partial
3 main types of generalised
3 types of partial
23
Q
3 main types of generalised epilepsy
A
Tonic/clonic
Absence (petit mal)
Myoclonic/atonic
24
Q
3 types of partial epilepsy
A
Simple partial
Complex partial
Simple sensory
25
Epilepsy triggers
No trigger (idiopathic)
Trauma such as head injury
CNS disease such as tumour, stroke, CJD, meningitis
Social cause such as late nights, alcohol, flashing lights
26
Generalised vs partial epilepsy
Generalised epilepsy affects all parts of body due to central focus in brain affected which spreads signal out to all parts of the cortex
Partial epilepsy can affect any neural modality in the body such as motor or sensation/perception
27
What is a tonic clonic generalised seizure And describe the seizure
Associated with prodromal aura where pt change in awareness/actions before seizure
Loss of consciousness/continence
Initial tonic (stiff) - all voluntary muscles contract together
Then clonic phase where intermittent contraction/relaxation of muscles
Most cases will spontaneously terminate after 1-3 mins
28
Describe petit mal (absence) generalised seizure
Short lived episodes 5-15 seconds
Often loss of awareness - eyelids flutter, vacant stare, stops activity, loss of response
Most often happens in children - mistaken for daydreaming
Can be multiple attacks in one day
29
Tonic clonic seizures medical considerations
Risk of injury
Remove objects from mouth if possible
Asphyxia - use supplemental oxygen and suction any secretions
30
Tonic clonic seizures social considerations
If pt pregnant can cause metabolism upset and medicines used for epilepsy can be harmful in pregnancy - most kept on meds understanding small risks to baby
Can cause sudden death due to asphyxiation/aspiration
Social - driving and employment etc
31
Describe partial seizures
Motor localised to one region of the brain
May move or spread to other motor areas…this is called Jacksonian seizure …Starts with small tremor which moves up to elbow, shoulder and neck
32
Sensory partial seizure
Any sensory modality affected…visual, auditory, taste, smell
May have aura beforehand and produce the feeling of deja vu
33
Describe complex partial seizures
Different areas of the brain affected which produce connected movements
Automatism…pt has no awareness
Repetitive purposeless movements
Lip smacking, grimacing
34
Epilepsy treatment
Anticonvulsant drugs…phenobarbitone, gabapentin, carbamezapine, lamotrigine (for tonic clonic) and levitiracetam for absence seizures
Emergency tx - airway and oxygen
Status epilepticus requires benzodiazepines
35
Epilepsy Drug mechanism of action
Benzodiazepines enhances GABBA receptor action on CL-
Valproate is a gaba transaminase inhibitor
Carbamezapine stabilises sodium channel
36
Surgery for epilepsy
Removal of focal neurological lesions
If focal seizures identifiable point of origin in brain
37
Dental aspects of epilepsy
Complications of fits…oral soft tissue injury and dental injury/fracture
Assess risk of fit and ask when last three fits took place… treat at times of low risk
Phenytoin can cause gingival hyperplasia
Bleeding tendency on valproate
Know emergency care
38
when is early pregnancy timed from
& where fertilisation occurs, when implantation occurs
* early pregnancy timed from date of conception
* fertilisation occurs in fallopian tube
* implants in uterus approx day 8/9
39
fertility issues factors
* age
* smoking
* BMI
* exercisedrugs
* low folate can cause neural tube defects - spina bifida - pregrant should take folic acid supplements
* alcohol - can cause neurological/developmental changes
* can use assisted conception - success decreases as womens age increases
40
define the stages of pregancy
* trimesters characterised by different stages of development
* 1st - structures of embryo forming, tissues differentiating
* 2nd - more specialisation and final differentiation
* 3rd - growth and changes necessary for successful birth
41
summary of maternal changes in pregnancy
* physical changes - increased weight and fluid volume - allows for blood loss during birth
* hormonal changes
* haematological changes
* CV changes
* coagulation changes
42
maternal changes in pregnancy
haematological
* increased production of RC, WC, platelets
* 20% increase in red cell mass
* increased platelet consumption makes platelets normal to low
* increased WC makes diagnosing infection difficult
43
maternal changes in pregnancy
hormonal changes
* increased oestrogen and progestogen
* act on kidney to increase renin secretion - increased salt and water retention - increases plasma volume to protect from haemorrhage at birth
* hormonal changes reduce insulin sensitivity - diabetes in pregnancy
* lower oesophageal sphincter relaxes and increaed abdominal pressure increases GORD
44
maternal changes in pregnancy
vascular changes
* relaxation of vascular smooth muscle - reduced peripheral resistence and reduced BP
* compensatory increase in HR by 25%
* vascular compression by uterus - vena cava and aorta
* difficulty with venous return when supine - treat mother propped to one side to prevent vascular compression
45
maternal changes in pregnancy
coagulation changes
* clotting factor production increases
* increased turnover of cell - fibrinolysis increases
* coagulation screen remains normal
* increased DVT risk
46
what not to eat during pregnancy and why
* raw/slightly cooked meat and raw firsh - risk of toxoplasmosis infection
* raw eggs - salmonella
* non pasteurised milk and cheese - listeria
* spicy, grilled and fried food - dyspenia
* marlin, tuna and shark - mercury toxicity
* internal organs of animals
47
foetal changes in pregancy
first trimester
* 0-14 weeks
* development starts at week 4 - zygote becomes and embryo
* embryo stage stops at week 10 after embryonic development and growth weeks 6-10
* foetus 10-14 weeks - features and limbs become developed
* miscarriage rate highest in first trimester
48
foetal changes in pregancy
second trimester
* from week 14 - 26
* hair, nails and eyelids start to form
* movement may be felt
* 18 weeks - toes and fingers formed and hearing starts to respond
* 20-26 final development of vision and senses
49
foetal changes in pregancy
third trimester
* from week 27
* growth
* nervous system maturation
50
placenta
blood circulation
umbilical cord
* placenta connects foetus to mother
* materal and foetal blood circulation do not mix
* in close proximity so nutrients can diffuse easily
* spread would occur at birth so if infction risk c section would decrease risk
* umbilical cord goes from placenta into where belly button now remains
51
stages of labour
* depend upon degree of dilation of crvix and how far baby positioned through
* 1st and 2nd stage to do with delivery of baby
* 3rd to do with delivery of placenta
52
labour - delivery aids
* forceps - pressing side of vagina away from babys head, should not have contact with babys head
* ventoux - suction cup applied to top of head
* caesarian sectin - made through abdomen then uterus
53
umbilical cord healing
* clamped after birth - allows baby to maintain own oxygenation
* vessels will shut off and allow umbilical stump to necrose and fall off
54
screening
FAST
* foetal abnormality screening programme
* 1st trimester 11-14 weeks
* ultrasoudnd
* maternal hCG blood test
* PAPP-P blood test
* combined results can suggest chromosome abnormality
55
screening in first trimester purpose
* establish dates of pregnancy
* determine number of foetuses and identify placental structures
* to diagnose ectopic pregnancy or miscarriage
* examine uterus and other pelvic anatomy
56
screening at 18-20 weeks purpose
* confirm pregnancy dates
* assist in prenatal tests such as amniocentesis
* check amount of amniotic fluid
* examine blood flow patterns
* observe foetal behaviour and activity
* monitor foetal growth
57
birth testing
* physcial examination
* hearing test
* blood spot - PKU, hypothyroidism, CF, sickle cell disease, MCADD
58
APGAR test
* tests responsiveness of baby 1 min after birth and 5 mins
* should be significant rise in score between the two
* Activity - muscle tone
* Pulse
* Grimace
* Appearance - colour
* Respiration - rate
59
dentirstry during pregnancy
* free dental care
* drugs may affect baby
* pregnancy gingivitis - due to change in hormone levels increasing vascularity of gingiva
* position of mother - not suppine as compresses vascular structures
60
definition of stroke
* acute focal neurological deficit resulting from cerebrovascular disease
* and lasting more than 24 hours or causing earlier death
* blockage of blood delivery of O2 to tissues
* infarction of tissue from hypoxia
* FAST - facial drooping, arm wekness, speech difficulty, time are signs of stroke
61
what is a transient ischaemic attack
* temporary disruption in blood supply to part of the brain
* results in lack of O2 to the brain
* temporary ischaemia NOT haemorrhage
* increased risk of proper stroke in future
* symptoms - FAST
* localised loss of brain function
* full recovery in 24 hours - most in 30 mins
* could be caused by platelet emboli
62
FAST symptoms of stroke/TIA
* facial drooping
* arm weakness
* speech difficulty
* time
63
risk factors for stroke
* hypertension - if diastolic over 110mmHg a x15 risk
* smoking
* alcohol
* ischaemic heart disease
* atrial fibrillation
* diabetes mellitus
64
causes of stroke
* ischaemic stroke - narrowing of vessels, plaques forming etc
* intracranial bleed - aneurysm rupture
* embolic stroke - caused by changes in L side of heart - AF, recent MI etc
* atheroma of cerebral vessels - carotid bifurcation, ICA, vertebral artery etc
65
less common causes of stroke
* venous thrombosis - oral contraception use, thrombophilia
* borderzone infarction - ischaemic lesions at junction between two main arteries
* vasculitis
66
prevention of stroke
* decrease risk factors - decrease smoking, diabetes control, hypertension control
* antiplatelet action as secondary prevention only - aspirin, clopidogrel, dipyridamole
* anticoagulants if embolic risk (AF, LV thrombosis) - warfarin, apixaban
* carotid edarterectomy if severe stenosis and previous TIAs
* preventative neurosurgery - aneurysm clips, AV malformation correction
67
investigation of stroke
* need to differentiate between causes
* early info needed to assess tx options
* use imaging - CT, MRI, digital subtraction angiography
* assess risk factrs - cardiac/carotid ultrasound, ECG, BP
68
imagine for stroke investigation and their uses
* CT scan - rapid, easy access, poor for ischaemic stroke
* MRI scan- difficult to do quickly, visualises early changes of damage
* MRA is best investigation for visualising the brain circulation
* DSA digital subtraction angiography - if MRA not available
69
effect of stroke
* loss of functional brain tissue
* immediate nerve cell death or nerve cell ischaemia in penumbra around infarction - area in surrounding tissue will die if not protected
* gradual or rapid loss of function
* inflammation in tissue surrounding infact/bleed...recovery of some function with time
70
management of stroke summary
* acute phase - limit damage and decrease future risk
* chronic phase - rehabilitation and decrease future risk
71
management of stroke
acute phase
* reduce damage - calcium channel blockers can help survival of penumbra region (survivable ishaemia)
* improve blood flow/oxygenation - thrombolysis possible within 3 hours
* stabilise blood sugar levels - hyper/hypo harmful
* remove haematoma - subarchnoid haemorrhage only
* prevent future risk - 300mg aspirin daily, anticoagulation if indicated (AF, LV thrombus)
72
management of stroke
chronic phase
* nursing and rehabilitation
* immoblility support - prevention of bed sores
* physiotherapy to prevent contractures (tightening of muscles, ligaments, skin etc)
* speech and language therapy
* occupational therapy
73
complications of stroke
* motor function loss - CN, somatic nerves (opposite side), autonomic in brainstem lesions
* dysphonia
* swallowing - risk of aspiration of saliva and food - pneumonia and death
* sensory loss - CN, somatic opposite side, body perception (neglect, phantom limb etc)
* cognitive impairment - understanding of info, speech and language difficulty
* memory impairment
* emotional lability and depression
74
dental aspects of stroke
* impaired mobility and dexterity - OH, attendance
* communication difficulties
* risk of cardiac emergencies - MI, further stroke
* loss of protective reflexes - apiration, managing saliva - could anticholinergic drugs help
* stroke pain - CNS generate pain perception
75
mental health act (scotland) 2003
summar
* different in scotland to rest of UK
* allows for detainment for treatment - purely psychiatric disorders
* no provision for tx of physical problems
* can have pts detained for tx - doesnt have to be at hospital can be in community
76
mental health act 2003 types of detention
* detention for assessment by doctor - for 2 hours to be assessed if emergency detention appropriate
* emergency detention - 72 hours pt will have to be assessed by mental health guardian to assess if detention is appropriate
* short term detention - 28 days
* compulsory treatment order - 6 months
* police have power to remove pt under act to place of safety
77
mental health act 2003 requirements/applications
* that the person has a mental disorder
* medical tx could stop condition getting worse or treat symptoms
* if tx not provided there would be risk to person or to others
* because of mental disorder impairment in medical decision making
* use of compulsory powers is necessary
78
psychistric illnesses broadly divided into two groups
* neurosis - pt retained with reality
* psychosis - pt lost with reality
79
psychiatric conditions present in dentistry
* neuroses - anxiety states, phobias
* psychoses
* eating disorders
* personality disorders
80
anxious pt
* from pts history might have good reason to be anxious
* dental anxiety not necessarily psychiatric diagnoses
* may not behave rationally from dentists perspective
81
types of neuroses
* anxiety
* phobic
* obsessional
* hypochondriacal
* depressive
82
anxious pt vs anxiety neuroses
* anxious pt concerned about dental tx
* anxiety neuroses concerned about everything
* ask pt if they are a worrier in general
83
types of anxiety disorders
* generalised anxiety disorder - free-floating anxiety in many/all situations
* phobic anxiety - intense anxiety/panic in specific situations
* panic disorder - unpredictable extreme anxiety
84
describe somatoform disorders
* repeated presentation of physical symptoms and request medical investigations despite negative findings
* symptoms have no physical basis
85
anxiety management strategies
* CBT
* psycho education
* breathing exercises
* drug tx - self medication (alcohol etc) or prescribed medication
86
anxiolytic drugs
* alcohol
* benzodiazepines - diazepam, midazolam, lorazepam
* antidepressants with anxiolytic features - tricyclic, SSRI
87
anxiety neuroses features seen in dentistry
* TMJ disorder and parafunction
* oral dysaesthesias - change in sensation percieved in mouth and face (dry, burning, pain)
* treat anxiety as well as symptoms
88
phobias summary
* fear/extreme anxiety out of preportion to threat/panic in specific situations
* if this is case ask about past experiences of pt and find out what trigger is
* other phobias may prevent dental treatment - claustrophobia, trypanophobia (injections etc)
89
OCD summary
* obsessive compulsive disorder
* cycle - anxiety - compulsion - relief - obsessions
* pt has anxiety and perform ritual to release anxiety
* cycle difficult to break
90
perfectionism vs OCD
* perfectionism - personality trait, may have habits or rituals, not doing it to avoid anxiety
* OCD - mental health disorder, compulsive action or ritual to prevent anxiety, ritual may not be related to anxiety itself
91
neuroses adjustment disorders summary
* maladaptive responses to severe past or continuing stress/trauma
* occur during adaptation to new circumstances - bereavement, trauma etc
* PTSD - stress of catastrophic nature
* managed by psychological intervention
92
mood disorder spectrum
* cyclothymia - normal mood swings
* depressive disorder
* recurrent depressive disorder
* unipolar
* bipolar affective disorder
* hypo-mania and mania are excessive form of wellbeing
* at both extreme ends (mania and severe depression) can have psychosis
93
types of changes in mood
* normal mood swings
* cyclothymic - slightly more exaggerated
* bipolar type II - more depression and not so much mania
* type I - extreme mood swings depression and mania
94
types of depressive mood disorders
* major depressive disorder
* bipolar depression
* postpartum depression
* seasonal affective disorder
* atypical depression
95
common symptoms of depression
* low mood
* reduced interest and motivation
* lethargy and tiredness
* sleep and appetite disturbance
* poor concentration
* loss of confidence/self-esteem
* recurrent thoughts of death and suicide
* any form of anxiety
96
mania and hypomania symptoms
* increased productivity and feeling of wellbeing
* reduced need for sleep
* increase in reckless behaviour - speeding, drugs etc
* followed by period of depression
97
treatment of mood disorders
* psychological - CBT, interpersonal psychotherapies
* drug tx - antidepressants and mood stabilising drugs - usually require two years even if pt mood returns to normal
* withdrawing before 2 years frequently associated with relapse of pt symptoms
* physical - exercise, phototherapy, ECT
98
acute phase antidepressants
* selective serotonin reuptake inhibitors SSRI - first line most commonly used - can promote anxiety when starting and stopping drugs so can sometimes get withdrawl symptoms
* tricyclic antidepressants TCA
* sometimes SSRIs combined with TCA
* monoamine oxidase inhibitor MAOI - lots of side effects and interactions so now only used by psychiatrists when other tx have failed
99
what are uses for antidepressants
* treat depression
* treat anxiety disorders - OCD/panic attacks
* pain relief - boost noradrenaline levels in brain to reduce pain transmission in CNS
* help psychological tx
100
examples of tricyclic antidepressants
* original types - amitriptyline, nortriptyline
* new - dexepin, imipramine
101
tricyclic antidepressants side effects/caution
* dry mouth
* sedation
* weight gain - reduction in feeling of fullness
* use with caution in glaucoma, prostasism
* dangerous in overdose
102
SSRI examples and side effects
* fluxetine
* paroxetine
* setraline
* side effects - acute anxiety disorders, sedation and dry mouth in some pt, GI upset
103
monoamine oxidase inhibitors example and interactions
* used as antidepressant
* phenelzine
* interaction with indirect acting sympathomimetic amines - enhanced vasoconstrictor effect
* foodstuff - alcohol, bovrilm marmite, cheese, beans
104
drugs used in bipolar mood disorder
* lithium (K+ substitute) mood stabiliser - avoid NSAIDs and metranidazole
* carbamezapine as mood stabiliser
* antipsychotic medicines for tx episodes of mania - aripirazole, olanzapine
105
antidepressant drug tx effect on dentistry
* direct drug effects
* dry mouth - caries rare link to lithium
* sedation
* facial dyskinesias - uncontrollable facial twitches
* no significant interaction dentist needs to be concerned about
106
types of psychoses and drug effects
* manic depression
* schizophrenia
* korsakoffs psychosis - alcohol induced brain degeneration
* drug effects - dry mouth, dyskinesias
107
describe schizophrenia
* thought disorder
* distortions of thinking and perception
* various types of dilusions
* auditory/visual hallucinations
* relapsing periods of acute psychosis
* causes - genetic susceptibility, environmental risk factors, drug abuse
108
schizophrenia management
* CBT
* family intervention
* drug therapy - oral or IM
* compliance with meds can be poor therefore IM can be good way to help
* dopamine antagonistic drugs can cause extrapyrimidal side effects (another card is on this)
* atypical antipsychotics less likely to cause extrapyrimidal side effects
109
antipsychotics examples
* haloperidol
* droperidol
* new atypical antipsychotics - sulpiride, clozapine
* atypical because they are not dopamine antagonists
110
extrapyramidal side effects of antipsychotics
* akathisia - restlessness, hard to hold still
* dystonia - muscles involuntarily contract and contort
* parkinsonism - tremor, slower movements, facial stiffness
* diskinesia - uncontrollable facial movements - can affect neck muscles and rarely intraoral muscles such as tongue
111
treating extrapyrimidal symptoms
* use atypical antipsychotic instead
* use betal-adrenergic blockers - propranolol
* use anticholinergic - benztropine - can also have side effects of dry mouth
112
types of eating disorders
* anorexia nervosa - altered perception of body image, restrict eating so oral effecrs of manutrition - ulcers, dry mouth, infections, bleeding
* bullimia nervosa - binge/vomit - dental erosion and oesophageal stricture
* comfort eating - eating disorder used as coping strategy for anxiety
113
types of personality disorder
* borderline personality disorder
* antisocial personality disorder
* narcissistic personality disorder
* avoidant personality disorder
* dependant personality disorder
114
symptoms of borderline personality disorder
* black or white thinking
* deep fear of abandonment
* unstable relationships
* changes in self image
* stress paranoia
* impulsive behaviour
* suicidal threats or self injury
* excessive mood swings
* loneliness
115
what is multiple sclerosis
* most common CNS disorder of the young
* changes to myelin sheath around nerve caused by inflammatory change - demyelination of axons
* progressive functional loss - can result in permanent neurological deficit and loss of function
* patchy distribution - typical for areas of body affected to change from time to time
116
multiple sclerosis
signs and symptoms
* muscle weakness
* cognitive changes
* depression
* blurred vision/visual disturbance
* numbness/pain
* difficulty walking
* balance/hearing loss
* tremor
* autonomic dysfunction
117
multiple sclerosis causes
* uknown
* more common in identical twins
* more common amongst immediate family members
* causes demyelination of axona
118
multiple sclerosis investigations
* history and examination
* magnetic resonance imaging
* CSF analysis - reduced lymphocytes, increased IgG protein
* visual testing
119
multiple sclerosis outcomes
* relapsing and remitting type - acute exacerbations and periods of respite - damage builds up with each episode
* primary progressive type - slow and steady deterioration
120
multiple sclerosis therapy
* symptomatic management - antibiotics, analgesia, steroids
* physiotherapy and occupational therapy
* disease modifying therapies - cladribine, siponomod
* stem cell transplant
121
multiple sclerosis dental aspects
* limited mobility - decreased ability to brush and access to service
* psychological disorder - mood difficulty decrease oral care
* treat under LA not GA as GA could onset damage within brain
* orofacial motor and sensory changes - suspect in younger pts - MRI
* chronic orofacial pain possible
* trigeminal neuralgia risk
122
what is motor neurone disease
* degeneration in the spinal cord - corticospinal tracts/anterior horns
* bulbar motor nuclei can also be affected (CN)
* more common in males
* most death within 3 years of diagnosis
* progressive loss of motor function
* death due to ventilation failure/aspiration pneumonia
123
motor neurone disease signs/symptoms
* weakness in ankle or leg
* slurred speech
* difficulty swallowing some foods
* weak grip
* muscle cramps or twitches
* weight loss
* emotional lability - crying or laughing in inapropriate situations
124
motor neurone disease treatement
* non effective
* physiotherapy and occupational therapy
* riluzole - some get 6-9months life extension
* aspiration prevention - PEG tube feed, reduce salivation
125
motor neurone disease
dental aspects
* decreased OH
* muscle weakness of head and neck - drooling
* realistic tx planning - increase QoL without decreasing expectancy
* drooling and swallowing difficulties - botox into salivary glands to decrease salivation or use of medications
126
what is parkinsons disease
* decreased NT dopamine in basal ganglia of brain - degeneration of dopaminergic neurones
* results in difficulty of message passing from thinking to doing brain
* quite common, disabling, progressive
* usually older people
* can lead to delays in pt understanding/doing things
127
parkinsons disease
signs and symptoms
* bradykinesia - slow movement and slow initiation of movement
* rigidity - increased muscle tone
* tremor at REST - when pt makes intentional movement will go away - key feature of parkinsons
* manifestation - falls, impaired use of upper limbs, mask-like face, swallowing problems
128
parkinsons disease
physical and surgical tx
* physiotherpay and occupational therapy
* work to maintain function at high a level for as long as possible
* stereotactic surgery - 3D techniques
* stem cell transplant ?
129
parkinsons disease
medical tx
* dopamine - levadopa - effective tx at beginning
* dopamine analogues :
* tablets - promixepole
* injection - apomorphine
* infusion - duodopa - directly into gut
* dose needs to continually increase to keep benefit and side effects eventually become intolerable (pt can have abnormal convulsions)
130
parkinsons disease
dental aspects
* difficulty accepting tx
* tremor at rest - often facial tremor reduces on purposeful movements eg opening mouth
* dry mouth - anticholinergic effects of the drugs
* drug interactions - check BNF before prescribing
131
examples of connective tissue diseases and summary
* systemic lupus erythematosis (SLE)
* systemic sclerosis (scleroderma)
* sjrogens syndrome (SS)
* undifferentiated connective tissue disease (UCTD)
* multisystem autoimmune inflammatory disease - complement activation causes tissue damage
* spectrum disorder - pt can have features of ant of these diseases
132
connective tissue diseases
vasculitic diseases
* poblem within BV wall - catergorised by size of BV
* large vessel disease - giant cell arteritis - affects arteries such as maxillary or temporal
* medium vessel disease - kawasaki disease
* small vessel disease - wegners granulomatosis
133
connective tissue diseases
general management
* dependant on disease activity
* analgesis NSAIDs for joint/muscle symptoms
* immune modulating tx - hydroxychloroquine, methotrexate, biologic medication (cytokine inhibitors and lymphocyte depleting drugs)
* systemic steroids - prednisolone
134
antibodies commonly found in autoimmune disease
* ANA - antinuclear antibody
* dsDNA - anti double strand DNA
* Ro - anti-RO antibody
* La - anti-La antibody
135
what is systemic lupus erythematosis
* multi system tissue changes
* 1 form tissue changes without blood autoantibodis called "discoid lupus"
* circulating immune complexes - do not have to be present but more likely to be present - ANA, dsDNA and Ro
136
systems systemic lupus erythematosis can affect
* joints
* skin
* kidney - renal involvement
* muscles
* blood
* CVS, RS and CNS - enhanced cardiovascular risk
137
systemic lupus erythematosis features
* photosensitivity common - butterfyl zygomatic rash
* genetic predisposition as well as environmental cause
* lupus nephritis
* arthritis
* raynauds phenomenon
* heart problems
* pleural effusions
138
systemic lupus erythematosis
dental aspects
* chronic anaemia - oral ulceration, GA risk
* bleeding tendance - thrimbocytopenia - check plt count beforehand
* renal disease - impaired drug metabolism
* drug reactions can cause photosensitivity
* steroid and immunosuppressive therapy - increased malignancy risk
* lichenoid oral reactions - looks like lichen planus
* oral pigmentation form hydroxychloroquine use
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what is lupus anticoagulant
* marker in the blood of some lupus pts
* not true anticoagulant - does not make pts blood less likely to clot
* anticoagulates blood in a test tube but not in a patient
* patients are termed antiphospholipid antibody syndrome
* primary form - no other associated disease
* secondary form - found in some patients with systemic lupus erythematosis, sjrogens etc
* antibodies : aPL (antiphospholipid) and aCL (anticardiolipin)
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what is antiphospholipid antibody syndrome and management
* characterised by recurrent thrombosis
* pts thrombophilic
* DVT with pulmonary embolism
* venous and arterial thrombosis
* pts anticoagulated - on warfarin
* do not stop anticoagulant as thrombosis risk could come back
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what is sjrogens syndrome
* inflammatory disease associated with circulating autoantibodies - ANA, Ro and La
* mainly associated with dry eyes and dry mouth
* major involvement of salivary glands - xerostomia and oral disease
* multisystem in some
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sjrogens syndrome
3 main groups
1. sicca syndrome - dry eyes or dry mouth
2. primary sjrogens - not associated with any other disease
3. secondary sjrogens - associated with another CT disease such as RA, SLE etc
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sjrogens syndrome
diagnostic criteria
* not one test proves sjrogens syndrome
* some signs/symptoms more important - dry eyes/mouth
* autoantibody findings
* imaging findings
* histopathology findings
* diagnosis often a clinical judgement
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sjrogens syndrome
oral and dental implications
* increased risk of oral infection and caries
* functional loss
* denture retention problem
* sialosis - inflammation of SG
* salivary lymphoma - unilateral gland size change
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what is systemic sclerosis
* excessive collagen deposition
* when elastic tissue of body replaced by fibrous CT fibrosis
* decreased ability to stretch skin etc
* localised or generalised forms dependant on antibodies present
* also affects internally - organs such as oesophagus will not stretch as well so decreased peristalsis
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systemic sclerosis
features
* mostly women
* gradual onset and slow progression
* raynauds phenomenon
* renal failure
* malabsorption (GI involvement)
* no tx to prevent
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systemic sclerosis
dental aspects
* involvement of perioral tissues - limited mouth opening, progressively poor oral access
* limited tongue movement
* plan tx 10 yrs ahead - carry out tx of poor prognosis teeth before limited access
* swallowing difficulties and reflux oesophagitis - dental erosion
* cardiac and renal disease - watch drug metabolism
* widening of PDL space due to CT changes - no dental mobility
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what is vasculitis
* inflammation of BV
* infarction of tissue
* may present as oral inflammatory masses
* may present as ulcers (tissue necrosis)
* vessel wall thickens with inflammation - narrowing of lumen reducing blood flow
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what is giant cell arteritis
* inflammation of the lining of your large vessel arteries
* commonly temporal artery involved - may be termed temporal arteritis
* can involve other carotid branches - central retinal artery (blindness)
* facial pain emergency
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giant cell arteritis/temporal arteritis markers/management
* no specific test
* ESR raised
* C-reactive protein raised
* plasma viscosity raised
* pt started on immune suppressants such as prednisolone as early as practicable
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describe polymyalgia rheumatica
* disease of the elderly- large BC affected
* causing pain and morning stiffness of muscles
* mainly around shoulder/hip area
* non-specific symptoms - malaise, weight loss, fatigue
* responds well to steroids
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describe kawasaki disease
* inflames the blood vessels of young children
* medium vessel disease
* fever and lymphadenopathy
* crusting/cracked tongue
* strawberry tongue and erythematous mucosa
* peeling rash on hands and feet
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describe wegners granulomatosis
* rare condition of unknown cause that develops as a result of inflammation in the blood vessels
* small vessel disease
* can lead to destruction of hard and soft tissues of face and oral cavity - spongy red tissue
* renal and resp tract most affeted
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what is fibromyalgia
* when symptoms of musculoskeletal problems but no evidence of active disease
* joint pain
* muscle pain
* functional disorders
* managed through pain management rather than immunosuppression
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dental aspects of vasculitic diseases
* steroid precautions may be necessary
* may present to the dentist:
* giant cell arteritis
* wegners granulomatosis
* kawasaki disease
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signs and symptoms of joint disease
* pain
* stiffness
* loss of function
* swelling around joint
* deformity - bones meet differently
* redness - inflammation
* crepitus - noise made by bone ends moving - loss of cartilage on bone ends
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joint disease investigations
* radiography - plain, MRI, arthrography - radiopaque die injected into joint to outline articular surfaces and joint capsule
* blood
* C-reactive protein - inflam marker CRP
* rheumatoid factor - autoimmune marker RF
* dsDNA, ANA
* arthroscopy and biopsy - allows clinician to look inside joint
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describe acute monoarthropathies
* only 1 joint in body affected
* acute arthritis of a single joint
* common causes include infection (septic arthritis) or gout (crystal deposits)
* can be initial stage of polyarthritis
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describe gout
* uric acid crystal deposition in joints
* significant pain from reactive inflammation
* caused by hyperuricaemia - high uric acid levels in blood
* less common in women until menopause - then equalises
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causes of hyperuricaemia
* drug induced - thiazide diuretics
* genetic predisposition
* nucleic acid breakdown - chemotherapy cancer tx
* tumour related - myeloma
* obesity and alcohol enhance
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gout symptoms/onset/tx
* acute inflammation of single joint
* usually great toe
* usually a precipitating event - trauma, surgery, illness, diet/alcohol excess
* rapid onset - hours
* NSAIDs to treat
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dental aspects of gout
* avoid aspirin - interferes with uric acid removal
* drug tx may give oral ulceration - allopurinol
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describe osteoarthritis
* degenerative joint disease - cartilage repair dysfunction
* cartilagenous layer on bone ends get thinner until disappears
* symptomatic in 10%, 60% show degenerative changes on X ray
* usually on weight bearing joints - hips and knees
* not wear and tear
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signs and symptoms of osteoarthritis
* pain - improves with rest, worse with activity
* brief morning stiffness
* slowly progressive over years
* radiographically - loss of joint space and subchondral sclerosis, ostephyte lipping at edge
* joint swelling and deformity - not common findings
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osteoarthritis tx
* treated symptomatically
* to improve pain
* increase muscle strength around joint
* weight loss
* walking aids
* NSAIDs
* prosthetic replacement
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dental aspects of osteoarthritis
* TMJ can be involved - seen on Xray - symptoms RARE
* difficulty in accessing care - decreased mobility
* chronic NSAID use can cause oral ulceration and bleeding tendency
* antibiotic prophylaxis for joint replacements? - most cases not required
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what is rheumatoid arthritis
* initially a disease of the synovium
* with gradual inflammatory joing destruction
* different patterns of joint involvement :
* sero-positive RA - rheumatoid factor present
* sero-negative RA - rheumatoid factor NOT present
* more common in females and peaks 20-50yrs - compared to osteoarthritis seen in old age
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joints that may be affected by rheumatoid arthritis
* symmetrical polyarthritis
* affects all synovial joints
* toes, ankles, knees, arms, shoulder, neck
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symptoms of rheumatoid arthritis
* slow onset - initially only hands and feet
* fatigue
* morning stiffness
* joint pain
* minor joint swelling
* SYMMETRICAL polyarthritis
* occ. onset of systemic symptoms - fever, weight loss, anaemia
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early signs of rheumatoid arthritis
* symmetrical synovitis of metacarpal pharyngeal joints
* symmetrical synovitis of proximal pharyngeal joints
* symmetrical synovitis of wrist joints
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late signs of rheumatoid arthritis
* ulnar deviation of fingers at metacarpal pharyngeal joints
* hyperextension of proximal pharyngeal joints
* Z deformity of thumb
* radiographically - loss of definition of joints and loss of stability - disturbed position
* subluxation of the wrist
* loss of external rotation and subluxation of shoulders
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function of replacement joint in RA vs OA
* in RA replacement joints provide functional change
* in osteoarthritis joint replacement is for pain
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extra-articular rheumatoid arthritis features
* due to systemic vasculitis - inflammation of blood vessels
* present in 75% of pts
* psoriasis in some - more aggressive in younger pt - psoriatic arthritis
* eye involvement - scleritis, dry eyes, sjrogens syndrome
* pulmonary inflammation
* subcutaneous nodles - pressure points
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rheumatoid arthritis investigations
* radiographs - erosions, loss of joint space, deformity
* blood - normochromic, normocytic anaemia
* increased use of CT and MRI
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tx of rheumatoid arthritis
* aim to improve quality of life
* physiotherapy - keep pt active for as long as possible - maintain muscle activity, improve joint stability and maintain joint position
* occupational therapy - maximising residual function, aids to dependent living
* drug therapy - to slow down process
* surgery
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tx of rheumatoid arthritis
drug therapy most cases
* analgesics for pain relied - paracetamol, cocodamol
* NSAIDs - often combined with anti-PUD agents
* disease modifying drugs:
* hydroxychloroquine, methotrexate - slow down immune process
* intra-articular steroids - injected into joint space
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tx of rheumatoid arthritis
drug therapy moderate and severe cases
* immune modulators - azathioprine, mycophenolate
* biologics - TNF inhibitors (infliximab, adalimumab)
* steroids - oral prednisolone
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tx of rheumatoid arthritis
surgery
* excision of inflamed tissue
* joint replacement
* joint fusion
* osteotomy
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dental aspects of tx of rheumatoid arthritis
* reduced dexterity and access to care
* often associated with sjrogens syndrome - dry eyes/mouth
* drug effects :
* bleeding - NSAIDs and sulphasalazine
* infection risk - steroids, azathioprine
* oral lichenoid reactions - sulphasalazine, hydroxychloroquine
* oral ulceration - methotrexate
* oral pigmentation - hydroxychloroquine
* chronic anaemia - GA problems
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RA atlanto-occipital instability
* RA can also cause damage to ligaments in the neck
* weakened atlanto-occipital joint can cause slipping of structures more easily - trauma to neck would increase chance of ligaments rupturing
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what are seronegative spondyloarthritides
* family of joint disorders
* ankylosing spondylitis - spinal joint arthritis - differs from RA as disease of axial skeleton vs RA peripheral tissues more
* reiters disease
* arthritis of inflammatory bowl disease
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seronegative spondyloarthritides
features
* association with HLA-B27 - genetic predisposition
* infection likely as precipitant
* often symmetrical peripheral arthritis
* occular and mucocutaneous manifestation
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ankylosing spondylitis summery and comparison with RA
* 95 % have HLA-B27 gene
* 8:1 male predominance
* onset about 20yrs - rare after 45 yrs
* whereas RA female predominance and peaks 20-50 years
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ankylosing spondylitis effects
* disabling progressive lack of axial movement - spine does not flex and bend so pt cannot bend forward or turn head
* symmetrical other joint involvement - eg hips
* low back pain
* limited back and neck movement
* limited chest expansion - breathing compromised
* kyphosis - cervical spine tipped forward
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ankylosing spondylitis tx
* generally same as RA
* analgesia and NSAIDs
* physiotherapy
* occupational therapy
* disease modifying drugs
* immune modulators
* surgery where appropriate for joint replacement
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ankylosing spondylitis dental aspects
* GA hazardous - limited mouth opening, limited flexion of neck
* TMJ involvement possible but rare except psoriatic arhtritis
* drug effects - see dental aspects of RA
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bone disease terminology
* arthritis - inflammation of joints
* arthrosis - non-inflammatory joint disease
* arthralgia - joint pain
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bone formation overview
* deposited by osteoblasts, resorbed by osteclasts
* deposit osteoid matrix - then mineralised to form bone
* bone is mineralised connective tissue
* bone turnover cycle takes 3-6 months and depends on - calcium, phosphate and vitamin D
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3 main features of bone
* load bearing
* dynamic - continuously changing - remodelling, adaptation, healing
* self repairing
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bone and calcium summary
* bone forms a store for calcium - some of it is exchangeable, some not
* exchangable calcium moves from bone into ECF
* calcium also absorbed from gut into ECF
* calcium lost through gut anf urine
* important that calcium maintained at very precise levels - as involved in nerve and muscle function
* bone and ECF work together with PTH helps promote correct location of calcium
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parathyroid hormone function
* maintains cerum calcium level
* raised if calcium levels fall
* increases calcium release from bone
* reduces renal calcium excretion
* increases active vitamin D so increased intestinal Ca absorption
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types of hyperparathyroidism
* primary - gland dysfunction eg tumour - high serum calcium results
* secondary - low serum calcium causes
* both result in increased bone reabsorption - radiolucencies
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vitamin D action
* produced from sunlight by cholecalciferol in skin
* processed by liver and kidneys to form active form
* active form necessary for calcium absorption in gut
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vitamin D problems
causes
* low sunlight exposure - housebond, dark skinned in northern country - skin absorbs sunlight less efficiently due to pigment
* poor GI absorption of vit D - poor nutrition, small intestinal disease (malabsorption)
* drug interaction - carbamezapine, phenytoin
* often a combination of factors
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what is osteomalacia and osteoporosis
* osteomalacia is when bone formed adequately and inadequate mineralisation - poorly mineralised osteoid matrix and cartilage growth plate - soft and pliable bone
* osteoporosis is loss of mineral and matrix but bone which is formed in normally mineralised - reduced bone mass
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osteomalacia types
* when it happens during bone formation - rickets as result
* after bone formation complete termed osteomalacia
* both related to calcium deficiency - when calcium in short supply
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osteomalacia investigations
* bones bend under pressure, pain, ache to touch
* decreased serum calcium and serum phosphate
* very high alkaline phosphatase - measure of bone turnover
* increased plasma PTH if secondary hyperparathyroidism
* increased plasma creatinine if renal cause
* hypocalcaemia effects - muscle weakness, carpal muscle spasm, facial twitching from VII tapping
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management of osteomalacia
* correct the cause
* malnutrition - control GI disease
* sunlight exposure - 30 mins X 5 weekly
* dietary vitamin D
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osteoporosis is
* reduced quantity of normally mineralised bone
* an age related change
* inevitable
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osteoporosis risk factors
* age
* female caucasian and asian
* endocrine associations - oestrogen and testosterone deficiency, cushings syndrome
* genetic - FH, early menopause
* pt factors - inactivity, smoking, excess alcohol, poor dietary calcium
* medical drug use - steroids, antiepileptics
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osteoporosis and gender
* more common in females
* males have higher peak bone mass
* oestrogen withdrawl at menopause increases bone mass loss rate in women
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osteoporosis effects
* increased bone fracture risk
* long bones - femur
* vertebae - height loss, kyphosis and scoliosis, nerve root compression - back pain
* lifetime risk of hip fracture increase
* after osteoporosis related hip fracture - increase in mortality risk and 40% unable to walk unaided
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osteoporosis prevention
1. build maximal peak bone mass
* exercise and high dietary calcium intake
2. reduce rate of bone ass loss
* continue as above and reduce hormone related effects - oestrogen hormone replacement therapy most effective if early menopause
* reduce drug related effetcs
* consider bisphosphonates
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osteoporosis hormone replacement therapy
* oestrogen only
* reduces osteoporosis risk
* increases breast cancer and endometrial cancer risk
* may reduce ovarian cancer risk
* increases DVT risk
* benefit lost after therapy stops
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bisphosphonates summary
* work by preventing osteoclast action by poisoning osteoclasts
* decreases number of osteoclasts
* non nitrogenous - etidronate, clodronate
* nitrogenous - alendronate, risedronate, zoledronate
* zolendronate once a year due to potency of drug
* benefit lost if drug discontinued
* can be combined with hormone replacement therapy
* risks of MRONJ XLA
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