Exam 1 Flashcards
What is the CCS Classification regarding angina pectoris?
➔ divided into 4 Classifications based on the ability to perform metabolic events (METs)
➔ CCS is used to categorize the functional severity of a patient with Angina pectoris
What is Class I of the CCS Classification regarding Angina Pectoris
(Ex tolerance: 7-8 METs)— ordinary physical activity doesn’t cause symptoms, only experience symptoms with strenuous physical activity [eg prolonged exercise]
What is Class II of the CCS Classification regarding Angina Pectoris
(Ex tolerance: 5-6 METs)— Slight limitation of ordinary activity — walking more than 2 blocks on level ground and climbing more than 1 flight of stairs without symptoms
What is Class III of the CCS Classification regarding Angina Pectoris
(Ex tolerance: 3-4 METs) - Angina occurs when walking 1-2 blocks at normal level and/or climbing 1 flight of stairs—shower/dress/make bed/play golf=no symptoms
What is Class IV of the CCS Classification regarding Angina Pectoris
(Exercise tolerance: 1-2 METs) ➔ Inability to perform any physical activity without discomfort; anginal symptoms may be present at rest
What is Congestive Heart Failure? (CHF)
a chronic progressive condition that affects the pumping power of your heart muscles. Ischemic symptoms are the result of oxygen deprivation secondary to reduced blood flow to a portion of the myocardium
What is the NYHA [New York Heart Association] for classification regarding Congestive Heart Failure
categorizes patients with congestive heart failure (CHF) based on their symptoms and functional abilities into 4 classes
What is Class I of the NYHA [New York Heart Association] classification regarding Congestive Heart Failure?
Asymptomatic — Patients with cardiac disease but without resulting in limitation or physical activity
What is Class II of the NYHA [New York Heart Association] classification regarding Congestive Heart Failure?
Symptomatic with moderate exertion — not symptomatic @ rest; ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain
What is Class III of the NYHA [New York Heart Association] classification regarding Congestive Heart Failure?
Symptomatic with minimal exertion
What is Class IV of the NYHA [New York Heart Association] classification regarding Congestive Heart Failure?
Symptomatic @ rest
PT [Prothrombin Time] is most frequently used to measure what?
the effect and status of oral anticoagulation therapy with warfarin
What is INR?
Due to the variations of responsiveness of the thromboplastin-to-anticoagulant effects in different laboratories performing PT test, the international normalized ratio (INR) was introduced to provide a means for standardization of PT results among laboratories
What is PT/INR Testing?
The INR expresses PT (Prothrombin Time aka how fast your blood clots) results as a ratio of the patient’s PT value divided by a control plasma PT value, which is then multiplied by the International Sensitivity Index (ISI) of thromboplastin.
What is a normal INR value?
➔ A “normal” INR value would be 0.9 – 1.2 however In our DMD-student dental clinics, routine, invasive dental treatment and simple oral surgery procedures may proceed if the patient’s INR is 2.5 or less
What does it mean when INR is higher than the recommended range? and lower?
higher ➔ it means that your blood clots more slowly than desired
lower ➔ means your blood clots more quickly than desired.
PT is most sensitive to deficiencies in the ________-dependent clotting factors II (prothrombin), VII, and X, also V.
vitamin K
PT is most sensitive to deficiencies in the vitamin K-dependent clotting factors _____, _____, _____, and ______
II (prothrombin), VII, and X, also V.
______ is the preferred method of
reporting PT results because it standardizes results among labs
INR
INR test must be taken _______ before the invasive procedure.
48 hours or less
______ is the device for measuring INR
CoaguChek
Who is responsible to make sure the consultation with pt’s Dr is done and INR is good for the procedure.
DMD Student
➔ At ULSD for DMD level treatment: patient must have INR < _____taken within ______ hours prior to invasive dental procedures.
However if patient has long history of stable INR (indicated by INR flow sheet) and no signs of easy bleeding/bruising, diagnostic or non-invasive procedures may be accomplished without what?
- 2.5
- 48
- recent INR
Patients taking warfarin requiring surgical procedures (ie extraction)-must be sent where at ULSD?
to graduate clinics/ ACB
T/F
Must send med consult for pt. on warfarin who need invasive dental tx.
True
What is most commonly used in the prevention of thrombosis and thromboembolism such as in patients with atrial fibrillation or prosthetic (mechanical) heart valves.
Warfarin
What test is used to monitor warfarin therapy?
PT/INR
Why is it hard to dose warfarin?
Therapeutic window is narrow: 4-7 mg/day
INR goal for pt who are being treated with warfarin is what?
- 2.0-3.0
(for some pts 2.5-3.5)
T/F
For most cases warfarin therapy should be discontinued because of dental treatments. THE RISK IS HIGHER THAN BENEFIT
FALSE
For most cases warfarin therapy should NOT be discontinued because of dental treatments. THE RISK IS HIGHER THAN BENEFIT
For high risk bleeding procedures discontinue warfarin ____ days before surgery
2-5
For warfarin patients at high-risk for thromboembolic complications, consider what during invasive procedures?
anticoagulant bridge therapy with enoxaparin (Lovenox).
(Low molecular weight heparin)
How soon after surgery is warfarin to be resumed after surgery?
Warfarin is resumed 12 to 24 hours after surgery (that evening or the next morning) and when there is adequate hemostasis.
Know the absolute contraindications for vasoconstrictors (9)
- CCS Class-IV angina pectoris (unstable or severe) - symptoms at Rest
- Within 30 days recent MI
- Within 30 days coronary artery bypass
- Symptomatic or significant arrhythmia
- Untreated or uncontrolled hypertension (greater than 180/110)
- Uncontrolled or uncompensated CHF
- Uncontrolled hyperthyroidism
- Sulfite sensitivity
- Pheochromocytoma - tumor on adrenal glands. produces too much fight or flight response
Know the relative contraindications for vasoconstrictors (7)
- Pt. with severe cardiovascular disease but not severe enough to be considered as absolute: controlled hypertension, stable angina etc.
- Pts with history of stroke (CVA)
- Pts taking/receiving Tricyclic antidepressant
- Pts taking/receiving Non-cardioselective beta blockers (propranolol) → risk of bradycardia followed by a hypertensive crisis.
- Pts taking/receiving Phenothiazine (antipsychotic drug)
- Pts taking/receiving inhalational anesthetic (ex: halothane)
- Pts taking/receiving serotonin/norepi reuptake inhibitors (SNRIs)
For post-MI patients that are no longer high risk/contraindicated for VC, limit the initial dose of the local anesthetic containing a vasoconstrictor to a max of:
- 0.036 mg of epinephrine (two 1.8mL cartridges of 2% lidocaine w/1:100,000) or
- 0.18 mg levonordefrin (two 1.8mL cartridges of 2% mepivacaine w/1:20,000 levonordefrin) within 30-45 mins
For post-MI patients that are no longer high risk/contraindicated for VC, when do you assess and record the pts. pulse and BP
prior to and 5 mins after admin LA, especially when containing a vasoconstrictor
What are additional precautions that should be taken when you have a post-MI patients that are no longer high risk/contraindicated for vasoconstrictor?
- Avoid use of epi impregnated retraction cord (consider a safer alternative: aluminum potassium sulfate impregnated gingival retraction cord instead)
- Avoid using LA w/vaso for direct hemostasis to control gingival bleeding
- Avoid using LA w/vaso for intraligamentary or infrabony infiltrations
If during dental procedure, more LA is necessary and .036 mg epi has already been administered at least 30-45 mins ago… options include what?
- Administer a LA without vasoconstrictor (3% mepivacaine plain or 4% prilocaine plain)
- Check BP and pulse…if within acceptable limits, admin additional LA with up to .018 mg epi (1 cartridge).
- Recheck BP and pulse 5 mins after injection
Know the common allergies that ULSD Problem-oriented Medical History Summary that will, or have the reasonable potential to, necessitate modification of normal dental protocols and procedures, or require special precautions, in order to prevent or reduce the risk of complications associated with the dental treatment of the patient
- Local anesthetic - Sulfites (this is the vasoconstrictor preservative. Ones w/out vaso are fine)
- Dental material - Mercury, nickel, methylmethacrylate
- Other materials used in dental treatment - Antibiotics
- If there is a concern that a patient has had an anaphylactic reaction to any dental material we may use, refer them to an immunologist for allergy testing
Know the Medical conditions that could result in potential medical complications secondary to physiologically stressful or invasive dental treatment (12)
a. Angina pectoris
b. history of myocardial infarction
c. History of cerebrovascular accident / transient ischemic attack
d. Cardiac insufficiency / congestive heart failure
e. Hypertension (BP >140 mm Hg systolic and/or 90 mm Hg diastolic)
f. Cardiac arrhythmia
g. Diabetes mellitus
h. Chronic obstructive pulmonary disease
i. Poorly controlled and/or exercise-induced and/or stress-induced asthma
j. Hepatitis, hepatic failure, or cirrhosis
k. Chronic kidney disease, renal failure and/or dialysis
l. Adrenal insufficiency
Know the medical problems or medications that places patient at an increased risk for post-treatment infection due to immunosuppression and/or delayed wound healing (7)
a. HIV/AIDS
b. Blood dyscrasias, aplastic anemia
c. Myeloproliferative disease (leukemia, myelofibrosis) lymphoma
d. Use of systemic corticosteroids and/or other immunosuppressive drug use {Tumor necrosis factor blockers (etanercept, infliximab, adalimumab, etc), Azathioprine, Methotrexate}
e. Undergoing antineoplastic cytotoxic chemotherapy
f. History of radiation therapy involving maxillofacial region
Status-post organ, bone marrow, or stem cell transplant
Know the Medical problems or medications that could result in clinically significant impaired hemostasis (7)
a. Hemophilia, von Willebrand’s disease
b. Thrombocytopenia, thrombocytopathia
c. Warfarin (Coumadin)
d. Direct thrombin inhibitors (Pradaxa)
e. Factor Xa inhibitors (Xarelto, Eliquis)
f. Low-molecular-weight heparin (LMWH) such as enoxaparin (Lovenox)
g. Valproic acid (valproate sodium)
Know what is included in History of a possibly unresolved infectious disease that could pose a transmission risk to others during dental treatment, despite the use of “universal precautions”
a. Tuberculosis
b. Pulmonary MRSA
What is the MDAS?
Modified Dental Anxiety Survey
score ranges from 5-25.
Higher number means more severe anxiety about dental visits
What dental devices have the potential to interfere with the proper function of a permanent implanted cardiac pacemaker / defibrillator.
- Avoid electrosurgery (greatest potential for interference)- the cauterizing wand used for gingivectomies. .
- Caution with ultrasonic scalers (cavitron)– can use just put box far away from pt.
- The following are theoretically capable of creating electromagnetic interference but negligible risk if kept 20-30 cm away: electrosurgery units, ultrasonic bath cleaners, ultrasonic scaling devices (cavitron), amalgamators, electric pulp testers, electronic apex indicators, composite curing lights, x-ray units, electric toothbrushes, and microwave ovens
- No contraindication for the use of any of these dental devices
Note that antibiotic prophylaxis is NOT required for these patients
What factors are considered when assessing the medical risk of a dental patient.
Medical history, physical examination, medical consultation, laboratory tests
Drug interactions, allergies, medical problems resulting in complications from stress/dental drugs, increased risk for metastatic infections/need prophylaxis, increased risk for post treatment infection from immunosuppression, impaired hemostasis, psychiatric/cognitive impairments, anxiety, infectious disease beyond universal precautions
What are the dental procedure invasiveness categories?
A way to differentiate between types of procedures, broken down into 3 main categories (non invasive procedures, nonsurgical procedures, and surgical procedures)
At what level of severity or (lack of adequate) control the cardiovascular diseases presented in the course would represent an unacceptable risk for elective invasive dental treatment.
- Canadian Classification System (CCS) Class-IV angina pectoris or unstable angina pectoris
- Recent (within 3 months) myocardial infarction (MI), transient ischemic attack (TIA), cerebrovascular accident (CVA) (stroke), coronary artery bypass surgery or angioplasty with stents.
- Severe, symptomatic valvular heart disease.
- Significant (severe) arrhythmia, including: symptomatic, refractory ventricular arrhythmia; supraventricular arrhythmia with uncontrolled ventricular rate; untreated Mobitz type II second-degree AV block, or third-degree (complete) AV block.
- New York Heart Association (NYHA) Class-IV congestive heart failure (CHF)
- Untreated or inadequately treated hypertension defined as a blood pressure greater than 180 mm Hg systolic or 110 mm Hg diastolic in an adult patient.
Infective endocarditis is caused by microbial infection of what?
cardiac valve leaflet endothelium and or mural endocardium
What causes infective endocarditis?
Can be bacterial (>90% cases), viral, fungal
Where does infective endocarditis most commonly develop?
Most commonly develops on mitral valve, aortic valve, both mitral + aortic tricuspid, rarely the pulmonic valve
Does infective endocarditis need prophylaxis?
· DO NOT NEED PROPHYLAXIS → Including: Implantable cardiac pacemakers or defibrillator, implantable vagus, spinal, or dorsal column stimulators, intra-aortic balloon pumps, arterial stents or grafts, prosthetic vascular patches/conduits, cardiac stents or peripheral vascular stents, cerebrospinal fluid shunts, inferior vena cava filter (greenfield filter), AV shunts, subq implantable drug delivery pumps, breast, penile, intraocular lens implants …etc.
Evidence for hematogenous infections in such patients with oral microorganisms is extremely limited or non-existent
AB prophylaxis is ______ recommended for patients with infectie endocarditis who undergo dental or other invasive procedures
not routinely
If the attending physician requests AB prophylaxis for infective endocarditis patients before dental treatment… what can the dentist do?
the dentist can state that there is no medical reason for such practice and request that the physician provide the prophylaxis.
_______ is the Most common of the inherited coagulation bleeding disorders”
Hemophilia A
Hemophilia A is a ______ bleeding disorder
congenital, x-linked recessive
A deficiency in what causes hemophilia A?
Deficiency in functional Plasma clotting factor VIII (F-VIII)
How prevalent is Hemophilia A?
1 in 5000 male births, more than 20,000 individuals in US have hemophilia A
How is the severity of Hemophilia A classified?
· F-VIII assays used to classify severity of the disease:
- Mild: 30%>X >5% (5-20 U/dL)
- Moderate >1-5% (2-5 U/dL)
- Severe < 1% (< 2 U/dL) spontaneous bleeding episodes
Normal values for F-VIII are what?
50-150 U/dL
What is Factor VIII concentrate (Humate-P) used for?
- Control spontaneous and traumatic hemorrhage in patients with hemophilia A
- The new recombinant factor VIII is stable w/o added human serum albumin (decreased risk of disease transmission)
Dose calculators for factor VIII replacement are directed toward achieving FVIII activity levels of what?
- 20-50% for most mild hemorrhages: gingival bleeding, simple oral surger
- At least 50% for severe bleeds (ie trauma), or prophylaxis prior to major dental oral surgery or general surgery
- 80-100% in life threatening hemorrhage
_______ that neutralize FVIII clotting function can cause replacement therapy to be ineffective in 30% of patients with severe Hemophilia A after exposure to Factor VIII concentrate
Alloantibodies (inhibitors)
In the 30% of patients with ineffective FVIII replacement therapy, bypassing agents such as _______ or
_______ can be used to treat bleeding
- recombinant activated factor VII (rFVIIa)
- anti-inhibitor coagulant complex(AICC)
- Recombinant activated______ became first choice of bypassing agents and is used to stop spontaneous hemorrhages and prevent excessive bleeding during surgery in 75% of patients with inhibitors
- Recommended dose is 70-90mcg/kg immediately _____ surgery, repeat every ____ hours for duration of surgery and until hemostasis is achieved
factor VII (NovoSeven RT)
- before
= 2-3
Patients with mild factor VIII deficiency can be managed in dental office for less invasive procedures such as what without factor VIII replacement
scaling, soft tissue surgery, simple extractions, etc
______ may be used in a dental office for patients with mild factor VIII deficiency
resulting in sufficient hemostasis to prepare patient for dental and minor surgical procedures
Desmopressin (DDAVP)
How does Desmopressin (DDAVP) work?
- acts via causing endothelial cells to release whatever they have in storage. This stimulates a transient increase in plasma FVIII levels
- IV: 0.3 mcg in 100mL saline sln infused over 30 mins (peak effect 30-60min)
- Nasal Spray: 150 mcg spray admin to each nostril (peak effect 60-90 min)
- A test dose of DDAVP should be performed before use. If test shows appropriate rise in FVIII level… at least 1 week should elapse before procedure. This allows time for replenishment of endogenous stores of FVIII
Besides Desmopressin (DDAVP), _____ and ________ are other options for patients with mild hemophilia A (can be used with DDAVP)
E-aminocaproic acid (EACA, Amicar) or tranexamic acid
Patients with moderate to severe FVIII deficiency with NO inhibitors will require _______ replacement prior to invasive dental treatment
FVIII
Dental extractions or mucosal procedures can be accomplished after single dose of Humate P, to achieve peak FVIII level of 20-50% along with a single 20 mg dose of EACA
Patients with moderate to severe factor VIII deficiency with alloantibodies (inhibitors) will require ______ prior to invasive dental tx to control bleeding.
recombinant activated factor VII (NovoSeven RT)
What are questions to ask yourself to assess bleeding risk?
What was the procedure, did bleeding start soon after surgery or delayed onset, length of time of prolonged bleeding, estimated amt of blood loss, what intervention was needed to manage bleeding, any procedures since the episode of excessive bleeding
What are factors to consider when assessing bleeding risk?
· Excessive bleeding after trauma
· Occurrence of spontaneous bleeding
· Use of any drugs that may cause bleeding
· Past and present illness associated with bleeding
· Presence of bleeding problems in relatives
· Have you ever had bruising with minimal/no trauma, especially if you could feel a lump under it?
· Have you ever had prolonged bleeding from a trivial wound lasting more than 15 mins or recurring spontaneous bleeding 7 days post wound?
· Spontaneous nose bleed?
· Bloody stool?
· Heavy menses w/ clots >1inch in diameter?
What is the “most common of all inherited bleeding disorders”
Affects 1-2% of US population
von Willebrand’s disease
What causes von Willebrand’s disease?
Caused by a deficient or defective von Willebrand factor- a multimeric protein that mediates platelet adhesion
- Type I von Willebrand disease is an autosomal _______ disease
- It is the _______ form
- dominant
- most common (75-85% cases)
How would you describe the deficiency of vWF in Type I von Willebrand disease?
- Mild to moderate quantitative deficiency in vWF 20-50% of normal levels
- mild abnormal bleeding
- Type II von Willebrand disease is an autosomal _______ disease
- It is the _______ form
- dominant
- less common (20-25%)
Type II von Willebrand disease has 4 variants (IIA, IIB, IIM, IIN) based on characteristics of _______ and is associated with ______ bleeding
- the dysfunctional vWF
- mild to moderate
- Type III von Willebrand disease is an autosomal _______ disease
- It is the _______ form
- recessive
- most rare, and severe
Type III von Willebrand disease has very little or no detectable ______ resulting in _______ bleeding disorder
- plasma or platelet vWF
- profound
The mainstay of dental management of vWD is what?
the replacement of the deficient vWF before performing dental procedures likely to result in bleeding
How is Desmopressin (DDAVP) useful for vWD? How would you use it?
- Effective for controlling bleeding from minor surgical procedures in most patients with mild type I vWD and some type II variants
- DDAVP is not effective in type IIA and potentially dangerous in IIB (increased risk of bleeding and thrombocytopenia)
- 0.3 mcg/kg in 100mL saline IV infused over 30 min (peak effect 30-60 min)
- Or Nasal spray if patient is >50kg: 300mcg (1 spray each nostril) prior to dental tx (peak effect 60-90min)
How is Humate P (factor VIII concentrate) helpful in patients with vWD?
- Useful to correct bleeding abnormalities in type IIA, IIB, III vWD without alloantibodies (inhibitors)
- vWF has a separate function of binding factor VIII coagulant protein and protecting it from degradation therefore a deficiency in vWF gives risk to a secondary decrease in factor VIII levels
How would you use e-aminocaproic acid (EACA, Amicar) in patients with vWD?
- 50-60mg/kg every 4-6 hours-> if pt is unresponsive to conventional methods
How iwould you use Tranexamic acid (adjunctive) in patients with vWD?
- 20- 25 mg/kg every 8-12 hours
- Can be admin orally, IV or topically as adjunct therapy concurrent with DDAVP or Humate P to improve hemostasis during oral surgery
What is ITP (idiopathic thrombocytopenic purpura)?
increased platelet destruction or excessive pooling
AKA, immune thrombocytopenic purpura or immune thrombocytopenia (They now tend to use “immune” instead of “idiopathic” for ITP since we now know the destruction of platelets is an autoimmune-mediated event)
Low platelet count is associated with what?
spontaneous bleeding, prolonged bleeding time, ecchymosis (bruise), petechiae
Platelet counts
20,000-50,000/µL signify what?
petechiae and ecchymosis observed following mild trauma
Platelet counts <10,000/µL signify what?
generalized petechiae, spontaneous mucosal/gingival bleeding frequently occurs
Platelet counts <2,000/µL signify what?
widespread ecchymosis, hemorrhagic bullae, spontaneous mucosal/gingival
For invasive procedures: platelet counts >_______ are desirable
50,000/µL
What is a Platelet count (PC) lab test measuring?
measure # of platelets in 1 µL of blood
Used for assessing bleeding disorders due to quantitative platelet defects (ie thrombocytopenia)
________ are the smallest elements in blood
Platelets (thrombocytes)
platelet development takes place in ______, 2/3 platelets are in circulation, 1/3 are in spleen.
marrow
What is the lifespan of platelets?
7-10 days
Platelets play a central role in _______ and formation of stable fibrin clot or platelet thrombus
- Adhere to subendothelial ______ exposed at BV injury via glycoprotein receptor complex
- Through the binding of plasma fibrinogen and vWF to integrin, a platelet ______ is formed.
- hemostasis
- collagens
- thrombus
If a patient has platelet disorders, what should you watch out for when treating them?
- Petechiae
- Ecchymoses (bruises)/hematomas (>1cm)
- Telangiectasias/spider angiomas
- Jaundice / pallor / cyanosis
If a patient has petechiae, what should you consider?
- Typical of severe thrombocytopenia (less commonly seen in other conditions such as severe platelet dysfunction disorders)
- Can also be caused by a viral infection, denture suction, excessive coughing or vomiting, palatal trauma.
Cardiac Glycosides
Example: Digoxin
Indications: Heart failure (HFrEF), atrial fibrillation
Mechanism: Increases myocardial contractility and slows AV node conduction
● Thiazide Diuretics
Example: Hydrochlorothiazide
○ Indications: Hypertension, heart failure
○ Mechanism: Inhibits sodium reabsorption, reducing blood volume
Loop Diuretics
Example: Furosemide
○ Indications: Heart failure, hypertension with fluid retention
○ Mechanism: Inhibits sodium, potassium, and chloride reabsorption in the loop of Henle
Sodium Channel Blockers
Examples: Lidocaine, Flecainide
○ Indications: Ventricular and atrial arrhythmias
○ Mechanism: Stabilizes abnormal electrical activity by blocking sodium channels
● Aldosterone Antagonists
Example: Spironolactone
○ Indications: Heart failure, resistant hypertension
○ Mechanism: Blocks aldosterone, reducing sodium retention and blood pressure
Angiotensin II Receptor Blockers (ARBs)
Example: Losartan
○ Indications: Hypertension, heart failure, diabetic nephropathy
○ Mechanism: Blocks angiotensin II, reducing vasoconstriction and aldosterone secretion
Beta-Blockers
○ Examples: Metoprolol, Carvedilol
○ Indications: Hypertension, heart failure, arrhythmias, post-MI
○ Mechanism: Blocks beta-adrenergic receptors, reducing heart rate and contractility
ACE Inhibitors
○ Example: Lisinopril
○ Indications: Hypertension, heart failure, post-MI, diabetic nephropathy
○ Mechanism: Inhibits ACE, reducing angiotensin II production and blood pressure
Potassium Channel Blockers
○ Example: Amiodarone
○ Indications: Atrial and ventricular arrhythmias
○ Mechanism: Blocks potassium channels, prolonging repolarization
Nitrates
○ Example: Nitroglycerin
○ Indications: Angina, acute heart failure
○ Mechanism: Dilates veins and coronary arteries, reducing myocardial oxygen demand
Antiplatelet Drugs
○ Examples: Aspirin, Clopidogrel
○ Indications: Prevention of heart attacks, strokes, stent thrombosis
○ Mechanism: Inhibits platelet aggregation, reducing clot formation
