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BDS3: BAMS > Haematology > Flashcards

Haematology Flashcards

1
Q

what are local factors of pseudomembranous candidosis?

A
  • antibiotic use
  • denture
  • local cotricosteroid use
  • xoerostomia - drug or radiotherapy induced
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2
Q

what are general factors of pseudomembranous candidosis?

A
  • Drugs
  • Extremes of age
  • Endocrine - Cushing’s syndrome Diabetes Mellitus
  • Immunodeficiency - Hereditary, Acquired
  • Nutritional Deficiencies - Fe
  • Smoking
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3
Q

what is atrial fibrillation?

A

Atrial Fibrillation(AF) happens when the electrical impulses in the atria of the heart fire irregularly chaotically when they should be steady and regular, causing them to quiver or twitch (fibrillation).

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4
Q

what are symptoms of atrial fibrillation?

A

Symptoms include feeling an irregular and sometimes fast, heartbeat or pulse. Some people say it feels like their heart is fluttering or racing (known as palpitations).

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5
Q

what is diabetes?

A

Diabetes is a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces.

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6
Q

what is type 1 and type 2 diabetes?

A

Type 1 diabetes can develop at any age, but occurs most frequently in children and adolescents. When you have type 1 diabetes, your body produces very little or no insulin, which means that you need daily insulin injections to maintain blood glucose levels under control. Learn more.

Type 2 diabetes is more common in adults and accounts for around 90% of all diabetes cases. When you have type 2 diabetes, your body does not make good use of the insulin that it produces. The cornerstone of type 2 diabetes treatment is healthy lifestyle, including increased physical activity

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7
Q

what are the risks of with diabetes?

A

Risk of hypoglycaemic episode – medical emergency
- Increases prevalence, progression and severity of periodontal disease
- Xerostomia
- Oral Dysesthesia (Burning Mouth Syndrome)
- Impaired wound healing
- Increased risk of infections and severity, including candidosis
- Parotid Gland Enlargement

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8
Q

what is hypertension?

A

High blood pressure is medically known as hypertension. It means your blood pressure is consistently too high and means that your heart has to work harder to pump blood around your body. High blood pressure is serious. If you ignore it, it can lead to heart and circulatory diseases like heart attack or stroke. It can also cause kidney failure, heart failure, problems with your sight and vascular dementia.

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9
Q

risk factors of hypertension?

A

Drinking too much alcohol
 Smoking
 Being overweight
 Not doing enough exercise
 Eating too much salt

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10
Q

what is secondary hypertension?

A

secondary hypertension. For example, an abnormal production of hormones from the adrenal glands can lead to high blood pressure. If your doctor gives you treatment for the hormonal condition, your blood pressure should then return to normal.

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11
Q

other causes for secondary hypertension?

A

kidney disease
diabetes, and
some medicines, such as oral contraceptives and some over the counter and herbal medicines.

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12
Q

what is warfarin?

A

The oral anticoagulants warfarin sodium, acenocoumarol and phenindione, antagonise the effects of vitamin K, and take at least 48 to 72 hours for the anticoagulant effect to develop fully; warfarin sodium is the drug of choice. If an immediate effect is required, unfractionated or low molecular weight heparin must be given concomitantly.lant

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13
Q

what are direct acting oral anticoagulants

A

Direct-acting oral anticoagulants (DOACs) include apixaban, dabigatran etexilate, edoxaban, and rivaroxaban. Dabigatran etexilate is a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation. Apixaban, edoxaban, and rivaroxaban are reversible inhibitors of activated factor X (factor Xa) which prevents thrombin generation and thrombus development.

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14
Q

what is simvastin?

A

HMG CoA reductase inhibitors and are used to treat hypercholesterolaemia.

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15
Q

what is furomeisde?

A

This medication is one of the loop diuretics. It is used in combination with other hypertensive medications to control resistant hypertension.

The loop diuretics can exacerbate diabetes however hyperglycaemia this is less than the thiazide diuretics

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16
Q

what is carvedilol?

A

This a beta blocker. When considered in this context for its use in the management of hypertension it gives us an indication that this gentleman is not receiving a first line treatment.

This should encourage us to consider the relevance of hypertension to our delivery of dental care.

Insulin – The prescription of this medication indicates that this gentleman is now dependent upon replacement of insulin

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17
Q

what is metformin?

A

Metformin hydrochloride has an anti-hyperglycaemic effect,

Metformin hydrochloride is recommended as the first choice for initial treatment for all patients, due to its positive effect on weight loss, reduced risk of hypoglycaemic events and the additional long-term cardiovascular benefits associated with its use.

Metformin can reduce Vit B12 levels, resulting in B12 decifiency anaemia

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18
Q

what is dapagliflozin?

A

Reversibly inhibits sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.

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19
Q

what is sulfonylurea

A

The sulfonylureas act mainly by augmenting insulin secretion and consequently are effective only when some residual pancreatic beta-cell activity is present; during long-term administration they also have an extra pancreatic action.

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20
Q

what is triple therapy of management of diabetes?

A

Metformin, Dapaglifloin and Sulfonylurea represents a triple therapy in the management of diabetes. It suggests that this gentleman has had challenges in achieving control of his condition which is also evident in the HbA1C.

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21
Q

what do you need if someone is on warfarin?

A

INR determines bleeding risk and warfin control

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22
Q

how would you manage canidosis?

A
  • consider nature and causes of disease
  • We should encourage the gentleman to:
    1. Use a toothbrush or some gauze to clean the palate. This could be supplemented with the short term use of Corsodyl mouthwash or gel
    2. Denture hygiene should be observed
    3. The patient should be encouraged to remove the denture at night
    4. Candidal species have the ability to penetrate the acrylic of dentures, therefore appropriate cleaning or even potentially a new denture may be required
    5. It should be reinforced that underlying causes should be consider and investigated
    If first line management fails, the use of medcations should be considered. Whenever considering the prescribing of medications we must evaluate the risk of interactions and consider the patients systemic health.
    It would be appropriate to start with a local agent in the management of pseudomembranous candidosis.
    a) Miconazole – This drug is contraindicated in patients taking warfarin as it potentiates the anticoagulant effect
    It is also contraincated for patient prescribed a statin as there is a possible increased risk of myopathy
    b) Nystatin
    This medication is safe to use in patients prescribed warfarin
    The use of systemic agents in the management of oral candidiasis should be considered as a final option for the majority or individuals
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23
Q

what drug contraindicates with warfarin and what do you give instead?

A

miconazole contraindicates
give nystatin instead

24
Q

what is INR?

A

An INR is a type of blood test and it is particularly useful for monitoring individual taking the medication warfarin.
The INR is a ratio. It is calculated by taking the prothrombin time (PT) of the patient and dividing it by a reference PT plasm value which has been corrected for the thromboplastin used in the test.

25
Q

what is healthy value of a normal person for INR

A

INR = PT/ref plasma val
normal = 1

26
Q

For patient described Warfarin, there are target ranges in which the patient’s INR should sit.
INR 2.5 for:

A
  • treatment of deep-vein thrombosis or pulmonary embolism (including those associated with antiphospholipid syndrome or for recurrence in patients no longer receiving warfarin sodium)
  • atrial fibrillation
  • cardioversion—target INR should be achieved at least 3 weeks before cardioversion and anticoagulation should continue for at least 4 weeks after the procedure (higher target values, such as an INR of 3, can be used for up to 4 weeks before the procedure to avoid cancellations due to low INR)
  • dilated cardiomyopathy
  • mitral stenosis or regurgitation in patients with either atrial fibrillation, a history of systemic embolism, a left atrial thrombus, or an enlarged left atrium
  • bioprosthetic heart valves in the mitral position (treat for 3 months), or in patients with a history of systemic embolism (treat for at least 3 months), or with a left atrial thrombus at surgery (treat until clot resolves), or with other risk factors (e.g. atrial fibrillation or a low ventricular ejection fraction)
  • acute arterial embolism requiring embolectomy
  • myocardial infarction
27
Q

For patient described Warfarin, there are target ranges in which the patient’s INR should sit.

INR 3.5

A

recurrent deep-vein thrombosis or pulmonary embolism in patients currently receiving anticoagulation and with an INR above 2;
Mechanical prosthetic heart valves:

the recommended target INR depends on the type and location of the valve, and patient-related risk factors
consider increasing the INR target or adding an antiplatelet drug, if an embolic event occurs whilst anticoagulated at the target INR.

28
Q

what if INR is >4

A

delay treatment

29
Q

when do you check INR?

A

no more than 24 hours before procedure up to 72 hours

30
Q

if INR is 4 can an extraction be done?

A

The INR value today is 4. The SDCEP guidelines state that the INR level should be less than 4 in order for a tooth to be removed safely.

31
Q

if they have regular warfin results taken?

A

Mr Fraser is having his INR taken at 3 day intervals. This would be deemed as a very frequent rate of assessment. This frequency of testing indicates that Mr Fraser is not stable in his warfarin control. This level of unpredictability needs to ne taken into consideration in order to safely manage Mr Fraser and therefore it would be appropriate to have an INR taken no more than 24 hours before the procedure, but ideally as close to the procedure as possible.

32
Q

what if results vary?

A

if results vary warfin control is bad

33
Q

how would you limit risk of bleeding for warfarin?

A

In order to limit the risk of bleeding the following should be considered:
1. Consider if the drug regime is short or long term. If it is short term only can the tretament be delayed
(Mr Fraser’s warfarin use is lifelong)
2. Plan the treatment for early in the day or week in order to allow time for the management of any complications
3. Undertake an atraumatic technique to dental extractions and surgery
4. Use appropriate measure to establish haemostasis
5. Consider the staging of treatment by limiting the initial area of surgery and evaluating haemostasis before proceeding, utilise haemostatic adjuvants and post-operative monitoring
6. Advise on the use of paracetamol analgesia unless contraindicated instead of NSAIDs
7. Provide full written instructions and emergency contact details

34
Q

how to do local haemostasis on extracted tooth of warafrin patient?

A

Local haemostasis
- Sockets should be gently packed with an absorbable haemostatic dressing: oxidised cellulose (Surgicel®), collagen sponge (Haemocollagen®) or resorbable gelatin sponge (Spongostan®)
- Sutures. Resorbable (catgut or synthetic (polyglactin, Vicryl®)) or non-resorbable (silk, polyamide,
polypropylene) sutures. Resorbable sutures are preferable as they attract less plaque.47 If non-resorbable
sutures are used they should be removed after 4-7 days.
- Following closure, pressure should be applied to the socket(s) by using a gauze pad that the patient bites
down on for 20 minutes.
- Atraumatic technique
- The use of tranexamic acid mouthwash, which acts as a local antifibrinolytic agent, is not routinely
recommended in primary care

35
Q

how would you treat someone on apixaban DOAC?

A

Step 1:
Evaluate and classify the risk:
If we refer to the SDCEP guidelines previously mentioned we are able to classify the risk of the procedure proposed. In this case the procedure is the extraction of a single tooth.
Do not exist standardized test for monitoring of DOACs, when it is necessary for monitoring of these drugs, eg, in hepatic and renal disease
As highlighted, we can determine that this procedure is a simple extraction of a single tooth and is therefore deemed of low risk of post-operative bleeding complications.
Step 2:
Change the drug regime as necessary
We have now established that removing a single tooth in a patient taking the medication apixaban is of low risk of post-operative bleeding complications.
If we then view the guidance relating to alteration in drug scheduling we are able to establish if a change in the drug regime is required.

Any changes to the DOAC dose schedule is only required for patients with a higher risk of bleeding complications. Therefore, as this patient requires only a single tooth to be removed he requires no changes to his scheduling. However, each clinician should still follow the general guidance contained within the document to reduce the risk of bleeding complications.
36
Q

how would you treat someone on apixaban DOAC that need multiple teeth out?

A

Step 1:
How would you classify the risk of this procedure in this patient?
This gentleman requires more than 3 teeth to be removed and a flap may have to be raised. Therefore in our risk assessment we should evaluate him as having a Higher risk of post operative bleeding complications.

If we now consider his dosing schedule, we realise that he is of higher risk and requires to have his schedule changed. He takes the medication twice daily. Therefore, we should ask him to miss his morning dose but then continue with their normal usual evening time dose provided it is no earlier than 4 hours after haemostasis has been achieved. it is important to review the bleeding after each tooth is removed and then further manage the situation. If the socket continues to bleed excessively this needs to be managed appropriately and then subsequently a decision needs to be made as to whether to continue treatment or stopping, having the patient assessed and returning to the treatment at another point in time. An alternative plan would be to stage the extractions further As before, consider the general advice given in the guidance documents.
37
Q

what risk of bleeding is an extraction of 1-3 teeth?

A

low risk of bleeding

38
Q

what if there is 3 teeth and a flap is raised?

A

high risk

39
Q

what if they are on apixiban and there is low risk?

A

nothing done

40
Q

what if they are on apixiban and there is high risk of bleeding?

A

ask them to miss morning dose and follow on doses rest of day as long as haemostasis has been achieved 4 hours after

41
Q

what is a swelling likely to be?

A

hemarthrosis
bleeding into a joint space and is associated with haemophilia.

42
Q

what is a common consequence of repeated hemarthroses?

A

damage to the articular cartilage

43
Q

what would intraosseous haemorrahge lead to?

A

bone resorption and development of bone cysts

44
Q

what is bleeding into the joints a sign of?

A

haemophillia

45
Q

what are the 2 types of haemophillia?

A

Haemophilia A – deficiency in Fact VIII, most common (85% of all cases)
Haemophilia B – deficiency in Factor IX

46
Q

what is the severity grades of haemophilia?

A

Severe = < 1% Factor present
Moderate = 2-5% Factor present
Mild = 6-40% Factor present

47
Q

what is safe to do to patients with haemophila?

A

Examinations and treatment which does not require manipulation of the mucosa are safe to deliver to patients with this condition.

In general, the delivery of supragingival restorations, crowns and bridges with the use of infiltration anaesthesia is safe to provide for people with haemophilia within the general dental practice setting.

48
Q

what should you do if a patient with haemophila requires and extraction?

A

However, for dental extractions, surgical procedures, subgingival scaling or anaesthesia requiring inferior alveolar nerve blocks of lingual infiltrations it is necessary for these patients to be seen at a dental clinic associated with a haemophilia centre. With these procedures there is an increased risk of bleeding which requiring medical prophylaxis and appropriate monitoring. Consideration should be given to the use of articaine infiltration and intraligamental injections to avoid IANBs

49
Q

what is used if a patient has mild haemophilia or von willebrand’s disease?

A

For patient with mild haemophilia or Von Willebrand’s disease, the use of DDAVP is normally undertaken to provide dental procedures which present an increased risk of bleeding.

50
Q

what is required if a patient has moderate or severe haeophilia?

A

For patients with moderate and severe haemophilia it is likely factor replacement will be required.

51
Q

why must you limit number of times a patient is exposed to factor replacement?

A
  • Risk of blood borne infections if plasma derived factor is used although blood products are comprehensively screened (recombinant factor is genetically made and therefore all but negates the risk BBV transmission)
  • Risk of local site infection
  • Risk of inhibitors / antibodies developing
  • Cost
52
Q

what is also used in management of patients with moderate and severe haemophilia?

A

Tranexamic acid, an antifibrinolytic agent

53
Q

what is steps of short term treatment plans?

A

acute management - this is to fix pain they have
prevention
stabilisation of disease

54
Q

what is done during mid term treatment plan?

A

prevention
re-evaluation
restorations

55
Q

what is done long term of treatment plan?

A

prevention
re-evaluation
restoration

BDS3: BAMS (8 decks)

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