General Medicine Flashcards
What are the cornerstone of medical evaluation?
- History taking
- Examination
- Special investigation
Why is rheumatic fever something we should worry about?
In some instances, rheumatic heart diseases may be exacerbated by increased bacteremia during certain dental procedures
What are some of common conditions should we worry about in terms of the cardiovascular disease section of the medical history?
- Heart failure
- Acute Myocardial Infraction
- Hypertension - high blood pressure
- Congenital Heart Disease - bacterial endocarditis
- Arrhythmias - related to heart failure and blood thinners
What is important aspects to assist a patient with general stress?
- Open communication about fears and concerns
- Short appoitment
- Mornign appoitment
- Ensure profound local anaesthesia
- Need to provide adequate post-operative pain control
- Post-procedure telephone call
What are some of common conditions should we worry about in terms of the blood disorders section of the medical history?
- Inherited bleeding disorders - haemophilia
- Anaemia
- Leukemia or blood dyscrasias
- Blood thinners
What are some of common conditions should we worry about in terms of the respiratory tract disease section of the medical history?
- Asthma
- Chronic obstructive airways disease
- Tuberculosis
- Sleep apnea or sleep disordered breathing
What are some of common conditions should we worry about in terms of the neurological disorders disease section of the medical history?
- Stroke
- Epilepsy, seizures and convulsions
- Behavioral/psychiatric disorders
What are some of common conditions should we worry about in terms of the endocrine disease section of the medical history?
- Diabetes - type I and type II
- Thyroid disease - uncontrolled hyperthyroidism and stress sensativity
What are some of common conditions should we worry about in terms of the genitourinary tract disease section of the medical history?
- Kidney disease - abnormal drug metabolism
- Sexually transmitted disease - HIV, Hep b and C
What are some of common conditions should we worry about in terms of the muscuskeletal disease section of the medical history?
- Arthritis - relating to TMJ and use of NSAIDS
- Prosthetic joints
What are some of the other conditions to look out for when conducting a thorough medical history?
- Tobacco and alcohol use
- Drug addiction and substance abuse
- Cancer treatment
- Use of steroids
- Pregnancy
- Previous operations or hospitalisations
What is considered to be normal blood pressure?
Any blood pressure where the systolic (first reading) is below 120 and diastolic (second reading) is below 80 e.g. 119/79
What is INR?
International Normal Rate is a test that identifies potential blood clotting issues by comparing them to an international norm (with 1 being norm and everything above is considered to be worst clotting = more bleeding)
What are the basic drugs and equipment that should be available at every dental practice required by law?
Drugs:
1. Oxygen
2. Adrenaline
3. Glucose
4. Bronchodilator
5. Aspirin
6. Hydrocortisone
Equipment:
1. Blood pressure monitor
2. Glucose monitor
3. Pulse oximeter
4. Automated external defibrillators
5. Laryngeal airways
What is syncope, what’s it’s causes and how do we manage it?
Syncope - transient self-limiting loss of consciousness. The onset is rapid and spontaneous and complete. Has presyncope phase of light-headed, nauseated, anxious and pale.
The underlying mechanism - cerebral hypoperfusion - i.e. low oxygen levels
Causes:
Vasovagal
Orthostatic
Cardiac dysrhythmias
Cardiac disease
Managmenet:
- Stop treatment
- Lie the patient down
- Support airway by removing all object for the mouth
- Measure the patient’s blood pressure and heart rate
- If the patient does not regain consciousness - call 000 begin DRSABCD
What are coronary ischaemia syndromes?
They are syndromes that result from coronary artery obstruction.
The main two that we should worry about are:
- Angina - cuases by temporary myocardial infraction from demand for more blood flow. It typically present as crushing central chest pain, radiating to left arm, neck of jaw
- Acute myocardial infraction - should be suspected if chest pain is unrelieved by nitroglycerin
What is the protocol of action if you suspect the patient having coronary ischaemia syndromes in chair?
- Stop treatment
- Measure: blood pressure, heart rate and pulse oximetry
- Assess consciousness
- To relieve symptoms use glyceryl as instructed, call the registered nurse
If patient reports pain to be THE WORST EVER DO:
1. Call 000
2. Give glyceryl to a patient with previous history of angina
3. Give aspiring 300 mg orally
4. Measure: blood pressure, heart rate and pulse oximetry
5. Start supplemental oxygen - call registered nurse
6. Provide reassurance
7. If patient loses consciousness - start DRSABCD protocol
What is cardiac arrest, what are signs and causes, what is the management of the patient?
Cardiac arrest is the stop of heart function.
Signs: no pulse, loss of consciousnes and respiration
Causes: ventricular tachycardia, ventricular fibrillation, asystole
Managment:
1. Stop dental treatment
2. Call 000
3. DRSABCD
What are the different severity of an asthma attack?
- Moderate/mild: Saturation level of oxygen in blood abover 94%
- Severe: Oxygen saturation of 90-94%
Life-threatning: oxygen saturation of less than 90%
What is the management of mild or moderate asthma?
- 4 puffs of slabutamol inhaler, 1 puff at a time, shaken before each puff
- Ask the patient to take 4 breaths in and out of the spacer after each puff
- Wait 4 minutes
- If no imporvement - repeate
- If no improvement again - define this as a sever or life-threatening attack
What is the management of sever or life threatening asthma attack?
- Call 000
- Start oxygen and airway support
- Salbutamol - 12 puffs for 6+ years, 6 puffs for less than 6 year olds
- 1 puff at a time, 4 breaths in between
- When waiting for help - perform the protocol every 20 minutes
- If patient is worsening - continuously administer salbutamol
What are the signs of partial airway obstruction?
- Wheeze
- Stridor (noisy inspiration
- Laboured breathing
- Coughing spasms
- Cyanosis
What are the signs of complete obstruction of the airways?
- Inability to breath, speak, cry or cough
- Agitation, gripping of the throat
- Cyanosis
- Bulging of the neck veins
- rapid development of respiratory failure
- Loss of consciousness
What are the steps of management if an inhaled object appears to have fallen down the oropharynx?
- Stop dental treatment
- Check for object location
- If not found, put the patient into an upright position
- Refer the patient for further medical assessment
What are the steps of management if the patient is conscious with signs of airway obstruction?
- Call 000
- Reassure the patient and ask them to relax, breete deeply and try to dislodge the object by coughing
- If coughing is ineffective - give upto 5 back blows between the shoulder blades - check between each hit
- If the back blows dont work, do 5 chest thrust similar to CPR
- Continue until assistance arrives
What are the steps of management if the patient is unconscious with signs of airway obstruction?
- Call 000
- Inspect the back of the throat for foreign object
- Start DRSABCD
- Consider performing cricothyroidotomy
- DO NOT DO THE HEIMLICH MANOEURVE
What are the sings and symptoms of stroke?
- Transient loss of consciousness
- Difficulty of moving one side of the body
- Confusion
- Difficulty speaking
What are the steps to managing a patient with a stroke?
- Stop dental treatment
- Call 000
- Measure: blood pressure, heart rate and pulse oximetry
- Start oxygen and airway support
- Monitor vital signs
What is the management of seizures?
If history of epilepsy or seisures is present - please use a bite block on the patient
- Stop dental treatment
- Ensure patient is not in danger
- Turn the patient to the side
- Avoid restrainning
- Wait until seizure stops
- Maintain airways
- Assess the patient
- If still unconscious, call 000 and maintain airways
What to do if you given the patient a partial paralysis of priocular muscles because of the injection intro the parotid plexus?
- Stop administratioe patchn of local anaesthetic
- Explain what happened
- Tell the patient to not rub their eye
- Close the eye with an eye patch
- Keep the patient under observation until the ability to blink starts to return
- Advise patient not to drive
- Phone the patient in 12 hours and make sure the issue resolved - if not refer for extra medical care
How to manage a person with hypoglycaemia?
- Stop dental treatment
- Give 15 g of glucose or a similar drink or food
- Measure blood glucose - if does not return to normal - repeat the dose
- If after 3 doses normal blood sugar not returned - call for help
- If unconscious call 000 than DRSABCD
How to manage a person with hyperglycaemia?
Call 000
When does an addisonian crisis occur and how to manage it?
Usually occurs in patient with hyperthyroidism or use of corticosteroids 6-12 hours after surgica; stress
Managment:
1. Call 000
2. Give hydrocortisone 200 mg
3. Think about GIVING MORE STEROID BEFORE PROCEDURES
What is step by step management of mild urticaria or angiodema?
- Stop dental treatment
- Remove or stop administration of the allergen
- Recommend oral anti-histamine
What is step by step management of extensive urticaria or angiodema ro swelling involving eyelids, lips or tongue?
- Stop dental treatment
- Remove or stop administarion of the allergen
- Refer for urgent medical attention; systemic corticosteroids may be indicated
What is step by step urticaria or angiodema with associated hypotension and evidence of anaphylaxis?
- Stop dental treatment
- Remove or stop administration of the allergen
- Call 000
- Give intramuscular injection of adrenaline
What is the step by step management of a patient with anaphylaxis?
- Stop dental treatment
- Remove or stop administration of the allergen
- Lie patient flat
- Give an intramuscular injection of adrenaline
- Call 000
- Start supplemental oxygen and airway support if needed
- DRABCD
- Repeat adrenaline every 5 minutes
What are the 5 most common and important cardiovascular diseases we should know about?
- Congestive heart failure
- Ischaemic Heart disease
- Cardiac arrhythmias
- Venous thrombosis
- Infective endocarditis
What is congestive heart failure, what is the aetiology and clinical features?
Definition: it is the inability of the heart, working at normal pressure, to pump enoughblood to meet the oxygen requirements of the body. Results from many diseases
Aetiology: mostly results from myocardial infreaction
Clinical features: tachycardia, neck vein distension, hepatic enlargement
What are potential ways to treat congestive heart failure?
- Treatment of systolic dysfunction with digoxin
- Reducing after-load on the heart with vasodilators like ACE inhibitors
- Reducing pre-load with diuretics and sodium restriction
What is atherosclerotic coronary artery disease, what is the aetiology and clinical features?
Definition: it is the focal narrowing of the coronary arteries as a result of the proliferation of smooth muscle cells and deposition of fats, The basic lesion is known as plaque.
Aetiology: the response to injury theory
1. Some injurious stimulus causes enodthelial damage - the chemical released during the damage cause proliferation of smooth muscle and migration of macrophages into the vessel wall - the damaged endothelium becomes more permeable to lipid and cholersterol into the intima
- These changes result in plaque formation, which becomes more disrupted leadin to platelets being activated and thrombus formation resulting in worsening obstructions
Clinical features:
1. Angina pectoris - chest pain or pressure caused by myocardial ischaemia
2. Myocardial infraction - necrosis of myocardial tissue
What are potential ways to treat angina?
- Non-pharmalogical - standard lifestyle changes
- Revascularization - coronary artery bypass grafting or other surgeries
- Pharmacological treatment - beta blocker, nitrates, calcium channel blockers or other
Important to know that treatment for unstable angina patient can not be treated - please talk to the cardiologist. If it is healthy - it is just important to tak ethat and potential medication into account. Timing is key in treatment - really stop and think about signs and sympotms of MI vs angina and get the to the hospital
What is atherosclerotic cardiac arrhythmias, what is the aetiology and clinical features?
Definition: refers to any variation in the normal heartbeat, includes disturbances of rhythm, rate or the conduction pattern of the heart
Aetiology:
1. Atrial tachycardia (popular treatment is oral anticoagulants):
1. Regular - Sonus tachycardia: physiological increase in the sinus rate above 100 bpm. Secondary to a disease process
2. Irregular - Atrial fibrilation: Irregurlarly irregular atrial rythm. Causes include stress, fever, MI
- Ventricular tachycardias:
- Regular - ventricular tachycardia: regular rhythm that occurs paroxysmally and exceeds 120 bpm. If sustained is a life threatening and leads to ventricular fibrilation - cardiac arrest
- Ventricula fibrillation: is a characterised by disordered contraction of the ventricles and therefore no cardiac output. Death unless conversion to an effective rhythm is accomplished.
What is atherosclerotic venous thrombosis (deep venous thrombosis), what is the aetiology, predisposing factors and clinical features?
Definition: DVT occurs when a blood clot forms in the lower extremities or the pelvic veins. The exact aetiology in unknown. Thrombi can become pulmonary emboli, this tendency is pronounced for clots above the politeal fossa.
Predisposing factors: varicose veins, immobilisation
Clinical features: Unilateral leg pain and swelling, tenderness, increase in the circumference
What are potential ways to treat DVT?
- Anticoagulants
- Rapid mobilisation, foot exercises and anti-thrombus stockings
What is infective endocarditis, what is the aetiology, predisposing factors and clinical features?
Definition: Infective endocarditis, also called bacterial endocarditis, is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel. IE is uncommon, but people with some heart conditions have a greater risk of developing it.
Predisposing factors:
1. Prosthetic cardiac valves
2. Previous infective endocarditis
3. Some congenital hear diseases
4. Cardiac transplantation with subsequent development of cardiac valvulopathy
5. Rheumatic heart disease
Dental procedures could induce harmful bacteremia - please contact the cardiologist for their needed anti-biotics
What are the most common antibiotics used for prophylaxis?
- Amoxicillin 2g 1 hour before procedure
- Clindamycin 600mg 1 hour before procedure
What are some of the important information that needs to be considered when treating a patient with congestive heart failure?
- Patient wit heart failure may have difficulty breathing thus may not tolerate a supone chair position
- Underlying condition causing heart failure may need special consideration
- Patient taking none selective beta blockers - need to consider the amount of epinephrine injected
What are some of the important information that needs to be considered when treating a patient with ischaemic heart disease (angina)?
- Need to reduce the stress and anxiety
- Patient taking none selective beta blockers - need to consider the amount of epinephrine injected
- Patient taking aspirin may have excessive bleeding
- Patient who had coronary artery bypass graft may require antibiotics
What are some of the important information that needs to be considered when treating a patient with ischaemic heart disease (myocardial infraction)?
- Need to reduce the stress and anxiety
- Patient taking none selective beta blockers - need to consider the amount of epinephrine injected
- Patient taking aspirin may have excessive bleeding
- Patient who had coronary artery bypass graft may require antibiotics
- Patient may have some degree of heart failure
- If patient has a pacemaker, some dental equipment may potentially cause electromagnetic interference
Remember of having INR of less than 3.5 and speak to the cardiologist
What are some of the important information that needs to be considered when treating a patient with cardiac arrhythmias?
- Need to reduce the stress and anxiety
- Patient taking none selective beta blockers - need to consider the amount of epinephrine injected
- Patient taking aspirin or warfarin may have excessive bleeding
- Patient who had coronary artery bypass graft may require antibiotics
- If patient has a pacemaker, some dental equipment may potentially cause electromagnetic interference
- Patient with preexisting arrhythmia are at an increased risk of serious complications such as angina, MI and other
Remember of having INR of less than 3.5 and speak to the cardiologist
What are some of the important information that needs to be considered when treating a patient with infective endocarditis?
- Dental procedures that involve the manipulation of gingival tissue or periapical region of teeth or perforation of the oral mucosa can produce a bacteremia
- Patient with mechanical prosthetic heart valves may have excessive bleeding following invasive dental procedures as the result of anticoagulant therapy.
Please contact cardiologist as some procedures may require anti-bacterial prophylaxis
What are some of the important information that needs to be considered when treating a patient with hypertension?
- Routine dental delivery to patients with uncontrolled hypertension could result in a serious outcome such an angina and myocardial infraction
- Stress and anxiety for dental visits may increase blood pressure
- Patient taking none selective beta blockers - need to consider the amount of epinephrine injected
- Some anti-hypertensive drugs can cause oral lesion or oral dryness and can predispose patient to orthostatic hypotension.
What is chronic obstructive pulmonary diseases?
It is a set of lung diseas that limit airflow and is not fully reversible. COPD patient report they are hungry for air.
What are the two most common cause of COPD?
- Chronic bronchitis - chronic inflammation and excess mucus (blue bloater) - difficulty breathing
- Emphysema - damage to the small, sac-like units of the lung that deliver oxygen into the lung and remove carbon dioxide (pink puffer) - none-efficient respiratory function
Man difference: bronchitis produces mucus and a lot
What is the pathophysiology of COPD?
- First should be an irritant - like cigarette smoke
- Irritant cause direct damage to the epithelial lining of the airways causing fibrosis of the said airways and damage to the cilia of the lungs
- There is alveolar wall destruction to to inflammation
- There is also mucus hersecretion from the goblet cells
What are the clinical signs and symptoms of COPD?
Symptoms:
1. Chronic cough with expectoration (mucus) - mostly associated with bronchitis
2. Shortness of breath
3. Wheezing
4. Chest tightness
Signs:
1. Tachypnea
2. Active use of accessory muscles
3. Barrel-shaped chest
4.Prolonged expiration - due to dead air retained within the chest
5.Rhonchi
What is the treatment for COPD?
- Smoking cessation
- Medication - bronchodilators. steroids and anti-biotics
- Treatments - avoidance of allergens. exercise and breathing exercise
What are some of the important information that needs to be considered when treating a patient with COPD?
- Avoid treating if upper respiratory infection is present
- Treat in upright chair position
- Avoid rubber dam in sever disease
- Use pulse oximetry in severe disease
- Avoid nitrous oxide/oxygen inhalation sedation with sever COPD - in order to not reduce the respiratory drive
- Avoid using narcoticts - in order to not reduce the respiratory drive
- Consider using steroids before the appoitment
What is asthma?
Asthma is an inflammation in the airways which makes the muscles in the airways constrict.
This causes the airways to narrow. The symptoms tend to come and go and vary in severity from time to time.
Treatment is to reduce inflammation and to open up airways usually works well.
What is related to sever asthma?
Frequent hospitalisation due to asthmatic attacks
What do we need to know about asthma?
- Identify and assess by history of astham - severity, irritants and levels of control are essential
- Ask the patient to bring their current medication
- Avoid NSAIDS and aspirin as they have an impact on inflammatory mediators and make asthma worst
- Patients taking chronic corticosteroid medications over the long term may require supplementation in a stressful situation like a dental procedure
- Provide stress free environment
- Recognise signs and symptoms of an asthmatic attacks:
- Inability to finish a sentence in one breath
- Ineffectiveness of bronchodilators
- Tachycardia
- Accessory muscle usage
- Tachypnea
- Sweating profusely
What is tuberculosis?
It is a human disease caused by mycobacterium tuberculosis. It is spread by inhalation of infected droplets. Long development period. Inflammatory and granulomatous response that result in pulmonary and systemic disease.
What is an important aspect to understand about tuberculosis?
It is a high infectious disease thus if you see a patient with persistent cough, previous hospitalisation and they are from susceptible countries - might need to go to the infectious disease specialist.
What treatment can we give to a patient with active tuberculosis?
Only emergency care, in the infectious disease word, isolated
What treatment can we give to a patient with previous history of tuberculosis?
Thorough history is important - contact their respiratory physician about the stage of their disease and procautions that they need.
If patient is confirmed free of disease than patient is safe to be treated as normal.
What is the difference about snoring and sleep apnoe?
Snoring and sleep apnoe are related concepts but are different pathologically.
What are the two main types of sleep apnoe?
- Obstructive sleep apnea
- Central Sleep Apnea - lack of breathing as a result of lack of CNS respiratory drive
What is snoring?
It is a result from the vibration of soft tissues of the upper airway, primarily through inspiration. It occurs without abnormal ventilation.
What is UARS?
Upper airways resistance syndrome - is a clinical entity midway between snoring and OSA. Occurs with snoring and associated with complaints of daytime sleepiness and fragmentation of sleep with some increased ventilatory effort.
What is obstructive sleep apnea?
It is a clinical condition that result in loud snoring and excess daytime sleepiness with complete cessation of breathing (apnea) or significantly decreased ventilation (hypopnea) due to airway obstruction during sleep.
What is the pathology of sleep related diseases?
Primary cause is anatomically narrowed upper airways combined with pharyngeal dilator muscle collapsibility.
The process of airways assessment is the following:
1. Nasal cavity
2. Nasopharynx
3. Oropharynx
What is the normal sleep cycle?
Normal sleep occurs in 2 phases: non-rapid eye movement (NREM) and rapid eye movement (REM).
Patterns can be measured by an EEG and presence of eye movement
What are the classifications of obstructive sleep apnea and how does it relate to sleep?
OSA depends on the degree and duration of obstruction, hypoxia, anoxia and hypercarbia.
OSA leads to arousal and transition to a lighter stages of sleep making the sleep fragmented.
Due to the lighter sleep, the restorative benefits of sleep are not achieved leading to cognitive and physiologic abnormalities.
What are 5 symptoms of OSA?
- Loud snoring
- Frequent wake-up
- Low concentration
- Poor work performance
- Poor short term memory
What are some of the potential way to manage OSA?
- General measures - weight loss, exercise, nsala decongestants
- Positive airway pressure machine
- Oral appliances
- Upper airway surgery - Powell-Riley protocol - ENT and maxilofacial surgery
What is the purpose of the mandible advancement device?
The main purpose is to protrude the mandible forward (and the tongue) in order to reduce the airway restriction.
Some association with TMD.
What are some of the basic facts we need to know about the patients cancer diagnosis?
- Have a basic understanding of cancer progression
- Basic knowledge of treatment modalities
- Understanding the various locations in which patient receive therapy
- Hvae basic understanding of cancer outcomes
What is cancer?
Cancer is uncontrolled growth of aberrant neoplastic cells.
It is often a destructive invasion of tissues by direct extension and spread to distant sites by metastasis via blood, lymph or serosal surfaces.
Uncontrolled proliferation of cell results in cancer but also neovascularisation of those cells is essential.
What is the normal pathway of progression for an oral cancer?
- Normal epithelium
- Leukpplakia that does not go away when wiped - hyperproliferative epithelium
- Epithelium dysplasia
- Oral cancer - carcinoma
What is the difference between incision biopsy and excitional biopsy?
- Incisional - small section of a lesion taken
- Ecsitional - all of the lesion is taken
What is the clinical presentation of a case or potential carcinoma?
- Change in surface colour of the lesion
- A lump or palpable mass
- Altered organ function
- Symptoms - pain and paraesthesia
What are the steps to management of carcinomas?
- History taking
- Examination
- Extra investigation - blood tests, x-rays etc
- Referral to cancer center
- Medical intervention
What are the 4 stages of cancer?
Stage I - localised and contained to the organ (T1 N0 M0)
Stage II - regional and nearby structures (T2 N0 M0)
Stage III - extensive beyond the regional site (T3 N1 M0)
Stage IV - widely dissaminated (any T N1 M1)
What is the difference between a cancerous lymph-node and a node during an infection?
Cancerous
1. Fixed
2. Enlarged
3. Rubbery and hard
4. None-tender
During an infection:
1. Can be rolled
2. Enlarged
3. Kinda soft
How to deal with an oral cancer?
- Do a biopsy
- Do CT scan
- Talk to the patient and provide information - good to ask a patient to bring someone else
What role do you have in treating a patient with oral cancer?
- Basic pretreatment oral evaluation
- Rule out oral disease that may worsen during cancer therapy
- Provide baseline for comparison and monitoring of sequelae of radiation and chemotherapy damage
- Detect metastatic lesions
- Minimize oral discomfort during cancer therapy
What are some considerations for a patient who has undergone radiotherapy for cancer in a context of tooth extraction?
They are at a high risk of osteoradionecrosis of the jaw.
It is a good idea to refer them to a head and neck surgeon.
What are sexually Transmitted Diseases?
STD’s are infections that are spread from person to person through intimate sexual contact. They are very easily spread thus they can be quite dangerous.
How are STD’s spread?
- Sexual intercourse
- Oral-genital contact
- IV drug
- Congenitally transmitted
What are the incrubale STDs?
- HIV/AIDS
- HPV
- Hep B
- Genital Herpes
What is syphilis and what are it’s common transmission?
It is an STD that is caused by the treponema pallidum bacteria. known as a “great imitator” it is able to imitate many different diseases.
Main modes of transition:
1. Sexual
2. Trans-placental
3. Percutaneous following contact
4. Blood transfusion
The dosage of exposure needs to be great and latent stages of syphilis may cause neural damage.
What is an oral manifestation of gonorrhoea?
An ulcer in the back of the mouth
What are some of the common oral manifestations of HIV infection?
- Oral candidiasis
- Herpes simplex virus lesions - Kaposi’s circoma
What are some of the common oral manifestations of HPV infection?
Condyloma accuminatum - please send to oral surgeon
What is coagulation?
Coagulation of the process of blood clotting, which is used to heal an injured blood vessel.
What is involved in haemostasis?
Haemostasis involves:
1. Vascular constriction
2. Platelet plugging
3. A fibrin mesh forming
What is the important aspects of history that might indicate a bleeding problem?
- Spontaneous bleeding from gingiva
- Spontaneous nasal bleeding
- Family history
- Drugs history - anticoagulants - woferin
- Viral infections
- Liver disease
- Cardiac disease
What are some of the signs you can note during examination that may indicate a haematological problem?
- Multiple purpurae of the skin
- Bleeding wounds
- Haematomas
- Swollen joint
- Liver disease signs and symptoms
- Cardiac disease
What are the 4 main pre-operative tests that may be ordered for a patient with bleeding problems?
- Bleeding time BT - platelet function test
- Activated partial thromboplastin time APPT - evaluation of the intrinsic coagulation pathway
- International normalised ration - INR - meaasurenment the extrinsic patway (1.0 is normal_ - please contact the cardiologist reagarding this
- Platelet count - quatify platelet function (normal range 150k-450k)
What are the most important bleeding disorders that we need to know?
- Coagulation factor deficiencies:
- Hemophilia A and B
-von Willebrand’s disease
- Vitamin K deficiency due to warfari use - Platalet disorder:
- Idiopathic
-leukemia
- Drug-induced - think aspirin - Vascular diosder:
-Scurvy
What are the two types of coagulation factor deficiencies?
1.Congenital:
-Hemophilia A and B
-Von Willebrand’s disease
2.Acquired
-Liver disease
-Vitamin K deficiency due to warfarin use
-Disseminated intramuscular coagulation
What is haemophilia A?
It is a deficiency clottin factor VIII or anti-haemolytic factor inherited X-linked recessive trait found in males.
Symptoms: delayed bleeding, deep haematoma, spontaneous gingival bleeding
Management: Increase factor VIII levels by replacing the factor or by inhibiting fibrinolysis. For dental extraction - email or talk to a haematologist for prescription of factor VIII replacement before the procedure and discuss additional platelet function increases, like desmopressin.
What is haemophilia B?
It is a deficiency clottin factor IX.
Symptoms: delayed bleeding, deep haematoma, spontaneous gingival bleeding
Management: Increase factor IX levels by replacing the factor or by inhibiting fibrinolysis. For dental extraction - email or talk to a haematologist for prescription of factor VIII replacement before the procedure and discuss additional platelet function increases, like desmopressin.
What is Von Willebrand’s disease?
It is the most common hereditary coagulation disorder. It is not sex linked.
Treatment is desmopressin and factor VIII concentrates in sever cases.
What are some of the systemic diseases that cause coagulopathies?
- Renal failure
- Hepatic failure
- Bone marrow
What are platelet disorders?
They can be hereditary or acquired and may be due to decreased platalet production, excess consumption or altered function. Platalets must be greater than 50k.
Treatment: Usually a replacement therapy 30 minutes prior to the procedure is enough for the patient. Idiopathic thrombocytopenic papura, an acquired platelet disorder, may require the use of oral steroid 7-10 days prior.
What is tranexamic acid?
It is compound that is used to decrease bleeding by supporting the formed blood clot be decreasing the production of blood clot destroying enzymes.
What are the four principal function of the urinary system?
- Excretory - excretion of water products and drugs in the urine
- Regulatory - regulation of the volume and the osmotic pressure of the blood
- Andocrine - kidneys produce several hormones that regulate blood pressure and production of red blood cells
- Metabolic - the kidney activated vitamin D which results in bone formation. In addition, the kidney is the major site for catabolism of important proteins such as insulin and parathyroid hormones
What are the parts of the renal system?
- Kidneys
- Ureters
- Bladder
- Urethra
What is a basic unit of the kidney?
The basic unit of the kidney is the nephron. They are millions of nephron per kidney.
What are the parts of the nephron?
- Glomerulus
- Bowmans capsule
3.Proximal tubule
- Distal tubule
- Loop of henle
- Collecting duct
What are renal disease?
They are different disorders that impact the renal system?
The two distinct types of renal diseases are the acute renal unsufficiencies and chronic renal failure.
Common diseases: Diabetes mellitus, arterial hypertension and other
What is chronic renal disease?
It is a progressive and irreversible decline in renal function associated with reduced glomerular filtration rate. GFR is measured using a creatinine clearance test.
CRD is the renal disease that manifests oral consequences most frequently.
Treatment for CRD:
1. Dietry changes
- Correction of systemic complication
- Dialysis
- Renal transplant
What is, generally, the first step of the parthenogenesis of kidney disease?
A reduction in the nephron number.
What are the oral consequences of kidney disease?
- Greater bleeding tendency due to reduction in platalets
- Hypertension due to extra blood volume
3.Anaemia
4.Drug intolerance - antibiotic and analgesics
- Increased susceptibility to infections
- Halitosis, burning sensation int eh mouth, uremic stomatitis, periodontal disease
- Xerostomia
- Impared healing
Please consider collaborating with a nephrologis
What are the steps to the dental management of a person who is on haemodialysis?
- Consultation with nephrologist
- Platelet dysfunction and anaemia resulting in bleeding tendency should be discussed
- Heparin anticoagulation can be given to patient who is on haemodialysis - thus maybe try to do a procedure on another day
- Avoid compression on the arm with the vascular access
- Do not presribe some drugs - check with MIMS or consult with the renal specialist
- Look out for renal osteodystrophy - there is weaker bone with those patients so extra care need to be taken care when performing surgery
What are the steps to the dental management of a person who had a kidney transplant?
- Consultation with nephrologist
- Platelet dysfunction and anaemia resulting in bleeding tendency should be discussed
- Risk of adrenal crisis if they are teated with long standing corticosteroid therapy: morning appoitment and consider the need of supplemental steroids
- Immunosuppression may require antibiotic prophylaxis prior to invasive dental procedures
- Disturbances in removal of drugs: care is needed prior to prescribing analgesia or antibiotics
- Gingival overgrowth as result of immunosuppressive drugs such as cyclosporin - also consider medication interactions
If anything beyond a clean is needed - please consider sending them to a specialist such a special needs dentist or a OMFS.
What information do we need to know about a patient with known diabetes?
- History of diabetes detection:
-Are you diabetic?
-What medications do you take for your diabetes?
-Are you treated by a doctor? - Establishment of severity of disease and degree of control?
-When were you first diagnosed as diabetic?
-What was the level of your las HbA1C sample?
What are the types of diabetes?
Type I - related to beta cell destruction and insulin deficiency
Type II - related to insulin resistance
Diabetets relating to pancreatic disease - cancers of the pancreas or others
Gestational - diabetes relating to pregnancy
What are the steps to dental management of a diabetic patient?
- Maximise blood glucose control - always tell the patient to go to the G
- Treat infections - due to the reduced immune function and healing - oral rinses, incision and drainage, extraction, antibiotics and other
What oral manifestations of diabetes?
Diabetes mostly affects the peripheral vascular tissue of the oral cavity
- Accelerated periodontal diseases
- Gingival proliferations
- Periodontal abcesses
4.Xerostomia - Poor healing
- Infections
- Oral ulcerations an candidiasis
- Numbness, burning and pain in oral tissues
What is the main reason for death in cocaine users?
Deaths usually occur as a result of cardiac stimulation, increase in blood pressure and arrhythmia.
Thus it is not recommended to use adrenaline containing LA within 48 hours after last dose of cocaine
What are some of the cautions that we may have for a patient with regular cannabis use?
- Xerostomia
- Oral cancer
- Anxiety exacerbation
- Vasoactive effect
It is recommended that patienr stay off marijuana for at least 1 week before LA with adrenaline. Might need to use adrenaline free LA.
What are some of the cautions that we may have for a patient with regular use of methamphetamine?
- Cardiovascular effect like arrhythmias
- Stroke
- Bruxism and clenching
- Xerostomia
- Meth mouth - rampant caries
These patient should be in close recall and the LA containing adrenaline should be avoided at least 24 hours after meth use.
Wht should be your general approach of managing a person of a general medical complication in the dental chair?
Consider
- Time of day for appointment
- Duration of the appointment
- Positioning of the patient
- Pre-procedure preparation/action plan - e.g. ask the patient to bring their medication
- Use of local anaesthetics
- Medications - contraindications, toxicities, interaction
- Caries risk
- Perio risk
- Xerostomia
How would you quickly assess the patients severity of COPD asthma?
- If they are managed situational by an inhaler - they are probably okay
- If they take medication - this may be a little more sus
- If they have been hospitalised - maybe consult with tutor
How does the diabetes damage the body?
Higher Blood glucose leads to advanced glycosylated end products (AGE) and free radicals which damage tissues - mostly on two levels
Microvascular damage - think perio
Macrovascular - think coronary artery disease and renal disease
