Haematology Flashcards
describe this soft tissue lesion
white mottled covering red mucosa of hard and soft palate down to uvula – whole width and depth
difference between candidiasis and leukoplakia
candidiasis can be brushed/rubbed off (may cause bleeding underneath)
leukoplakia cannot
radiographic report
OPT full mouth
grade A – no overlaps, clear
pathology
- caries – distal 38
- periapical – radiolucency of 37, mesial 17, 36
- bone – use BSP flowchart – distal 38 is in middle 1/3 (50%/65 = 0.7)
dx perio
age 65 male
smokes 5 daily
21 units of alcohol per week
diabetes
use BSP flowchart
bone – distal 38 is in middle 1/3 (50%/65 = 0.7)
Generalised perio, stage 2, grade B (smokes, diabetes, OH)
dx this soft tissue lesion
white slough in his palate over the past few weeks
‘the blood pours out of my palate’
Pseudomembranous Candidosis
- fungal infection
- opportunistic – medication; smoking; dry mouth (medications), denture wearer if not good denture hygiene, steroid inhalers, nutritional deficiencies
undertake investigations until potential causative factors - local or generalised
local factors for candidosis infection
antibiotic use
dentures
local corticosteroid use
xerostomia - drug induced; radiotherapy induced
general factors for candidosis infection
drugs
extremes of age
endocrine - Cushing’s sydrome; diabetes mellitus
immunodeficiency - heriditary, acquired
nutritional deficiences - Fe
smoking
explain possible causes for wide spread caries
pt retired, diabetic, poor OH
- Has a higher and frequent intake of cariogenic foodstuffs
- Performs oral hygiene once daily
- May have a dry mouth due to medications and diabetes
- can be worsened by role of caffeine in tea and coffee (acknowledge as a diuretic)
- significance of this role is dependent upon a number of other factors but may be worsen the situation if consumed in excess
- can be worsened by role of caffeine in tea and coffee (acknowledge as a diuretic)
what is dx for 37
periapical periodontitis
atrial fibrilation link to oral health
can result in complications
- pulmonary embolism PE
- deep vein thrombosis DVT
- cerebrovascular accident CVA/stroke
- myocardial infarction (heart attack)
pts in AF are anti-coagulated if cardioversion is not indicated or unsuccessful
diabetes link to oral health
- risk hypoglycaemic episode – medical emergency
- periodontal disease
- delayed healing
- salivary gland dysfunction
- oral dysesthesia
hypertension link with other medical conditions
significant risk factor for several medical diseases:
- heart disease
- heart attacks
- strokes
- heart failure
- peripheral arterial disease
- aortic aneurysms
- kidney disease
- vascular dementia
warfarin and apixaban
are anticoagulants (apixaban is NOAC)
warfarin mechanism
vitamin K antagonist
- anticoagulant for atrial fibrillation (irregular heartbeat)
- reduce risk of stroke
NOAC benefits
means no regular blood tests
- Good for pts, less monitoring needed
- More complicated for extractions
e.g. apixaban
simvastatin
HMG CoA reductase inhibitors
- Used to treat hypercholesterolaemia
- May have interactions with other drugs that you may prescribe
furosemid
Loop diuretics
- Used in combination with other hypertensive medications to control resistant hypertension
Can exacerbate diabetes – however less risk of hyperglycaemia when compared to thiazide diuretics
carvedilol
Beta blocker
- When used in hypertension management – its not first line Tx (so not responding well)
Individuals on non-selective beta blockers – heightened sensitivity to effects of vasopressors in LA
- Cause increase vascular resistance with a subsequent increase in BP – MEDICAL EMERGENCY
- MI and stroke can occur
Risk is small in dentistry – prevented by appropriate drug selection and LA technique
- Use adrenaline free
- Harder to achieve haemostasis but safer
insulin for diabetic
Prescription indicates that he is dependent upon replacement insulin
Additionally, consider timing of appointments
- Ensure blood glucose levels are appropriate for treatment and not coincide with time of peak insulin activity as causes risk of hypoglycaemia
metformin hydrochloride
Has an anti-hyperglycaemic effect
Recommended as first choice for initial treatment for all patients with diabetes
- positive effect on weight loss
- reduced risk of hypoglycaemic events
- long term cardiovascular benefits associated with use
any changes in blood can lead to
clot risk
- stroke
- DVT
hypertension
key things to know prior to carrying out any dental tx
Need to know stage
- Uncontrolled hypertension may need to be controlled before the delivery of dental treatment
Hypertensive crisis is a medical emergency (>180/110)
If dental anxiety is a trigger for a significant dangerous increase in blood pressure – maybe consider sedation
hypertensive crisis
>180/110
medical emergency
diabetes
key to know before dental tx
Establish diabetic control – inform diagnosis and stage dental Tx
HbA1c test is an average of last 3 months sugars
would you provide any tx to pt with this history who provided this history only
Atrial Fibrillation, Diabetes, Hypertension
currently on Warfarin scheduled Apixaban
Other meds: Simvastatin, Furosemide, Carvedilol, Insulin, Metformin
Complex medical history
Many issues raised that you need more information on before providing any operative treatment
- Risks of dental treatment
- Measures needed to ensure safety of pt
today provide intial preventative tx
- long term maintenance of oral health
what to get before doing any potential invasive bleeding risk procedures on warfarin pt
INR
warfarin and candidosis
warfarin interacts with antifungals - need to manage - liaise with GDP
why may this pt have a candidosis infection?
65 yo male
Atrial Fibrillation, Diabetes, Hypertension
currently on Warfarin scheduled Apixaban
Other meds: Simvastatin, Furosemide, Carvedilol, Insulin, Metformin
- Diabetic control
- Implication of medications
- May also have anaemia
- Missing teeth – likely wear RPD (esp as business man) – can be local factor
management of candidosis
Candida exist in biofilm
- Observe principles of biofilm management and consider mechanical disruption
- Increase in resistance to candida to drug therapies
- Use a toothbrush or gauze to clean palate – can be supplemented with short term use of Corsodyl mouthwash or gel
* Clean damp toothbrush – will be sore and inflamed - Denture hygiene observed
- Remove denture at night
- Clean – over sink filled with water, with toothbrush and liquid soap or effervescent tablets, rinse
- Leave out as much as possible until candida clear – can penetrate denture, may need new one
- Topical gel can be used to line RPD
If first line management fails – consider medications but
- Pt systemic health
- Interactions with Warfarin
Fluconazole capsule interactions (Common)
warfarin - impact INR
statins - muscle aches and pains
nystatin
topical antifungal
liquid - rinse and spit, 4 times a day
local, strong effect
safe to use on warfarin pts
miconazole
contraindications
- Contraindicated in pts taking warfarin
- it potentiates the anticoagulant effect
- Contraindicated in statins
- increased risk of myopathy
staged management of pseudomembranous candidosis
start with local agent (nystatic, miconazole)
go to systemic agents as final option (fluconazole)
INR
International normalised ratio
- Blood test particularly useful for pts on warfarin
- Prothrombin time (PT; time for plasma to clot) of pt divided by a reference PT value
Normal healthy individual is 1
For warfarin patient there is target ranges
- Below 4 happy to extract
Ideally within 24 hours of appointment
- If stable, maybe longer
- not stable if other sig risk factors – poor control diabetes etc, new pt)
target healthy INR
1
warfarin INR range
below 4 happy to do dental extraction
INR calculation
prothromin time (PT - time for plasma to clot) or pt
divided by
reference PT value
INR change due to (4)
diet - cranberry, grapefruit, pomegranate
medications - amoxicillin, warfarin level
hormones
stress
SDCEP
INR for safe to extract for warfarin pt
below 4
if INR is taken at 3 daily intervals indicates
Very frequent
Not stable
- Unpredictability – how safely can he be managed
- Need INR at least 24 hours before procedure but ideally as close as possible
what does a variance in INR in short time frame indicate
Warfarin control not as good as it could be
- higher risk of complications
- Post-operative bleeding
Can be due to changes in lifestyle, stress, drink and diet, medications (antibiotics)
7 considerations to limit the risk of bleeding if there is many teeth to be extracted for a haematological pt
- If the drug regime is short or long term – if it is short term only can the treatment be delayed
* His warfarin use is life long - Plan the treatment for early in the day or week to allow time for management of any complications
- Undertake an atraumatic technique to dental extractions and surgery
- Use appropriate measure to establish haemostasis
- Consider the staging of treatment by limiting the initial area of surgery and evaluating haemostasis before processing, utilise haemostatic adjuvants and post-operative monitoring
- Advise on the use of paracetamol analgesia (unless contraindicated) instead of NSAIDs
- Provide full written instructions and emergency contact details
how to prevent excessive bleed peri-operatively
Cotton wool to help stop bleed – don’t leave in as infections risk
PACK – matrix/mesh for clot to form around
- Blood more stable
- Less change of breakdown
- Can help haemostasis
Surgicel or caltistat
post op extraction instructions
- rest - avoid physical exercise or manual labour that will cause increase in blood flow for 24 hours
- Avoid eating on that side
- Avoid too hot/ too hard
- Avoid smoking for as long as possible
- Avoid rinsing mouth
- wait at least 6 hours, ideally 24
- After lunch – if extracted first thing
- After dinner - if midday extracted
- Gentle warm salty water to bathe area – tip head back
- wait at least 6 hours, ideally 24
Bleeding – provide gauze to bite on, if used use clean kitchen roll/towel/cotton wool bite for 20 mins – time
- Emergency contact number if unable to stop bleeding after 20 mins
requirements for warfarin extraction pt prior to app
Planning:
- appointment early in the day and early in week to allow appropriate time for review
Check INR:
- preferably 24 hrs before extraction but acceptable up to 72 hours where the INR is stable
local measures to achieve haemostasis
LA
haemostatic aids
sutures
pressure
atruamatic technique
tranexamic acid mouthwash
tranexamix acid mouthwas
acts as a local antifibrinolytic agent is not routinely recommended in primary care
3 local haemostatic aids to pack socket with
- Oxidised cellulose (Surgicel)
- Collagen sponge (haemocollagen)
- Resorbable gelatin sponge (spongostan
suture options
- Resorbable (catgut or synthetic (polyglactin, Vicryl) – preferable as they attract less plaque
- Non-resorbable (silk, polyamide, polypropylene) – remove them after 4-7 days
LA use for haemostatic aid
Containing vasoconstrictor should be administered by infiltration or by intraligamentary injection where practical (close to surgery site)
- Short 27 gauge needle to minimise tissue damage
Regional nerve blocks avoided when possible – if no alternative, administer LA cautiously with aspirating syringe
4 NOACs
apixaban
dabigatran
edoxiban
rivoroxiban
apixaban
mechanism of action
Factor Xa Inhibitor
test chromogenic anti-Xa assays
edoxiban
mechanism of action
Factor Xa Inhibitor
test chromogenic anti-Xa assays
rivoroxiban
mechanisms of action
Factor Xa Inhibitor
test chromogenic anti-Xa assays
dabigatran
mechanism of action
direct thrombin inhibitor
test - diluted thrommbin time (dTT); Ecarin-based assays such as ecarin chromogenic assay (ECA)
benefits of NOACs (6)
- predictable pharmacokinetics and pharmacodynamics
- rapid onset and offset - short half life
- low drug-drug and food interactions
- no dietary restrictions
- in general, no need for labratory monitoring (some cases need)
- wide therapeutic window
5 weaknesses of NOACs
- do not exist standardised test for monitoring of NOACs, when it is necessary to monitor them e.g. hepatic or renal disease
- sometimes rapid offset and short half life may be considered disadvantage
- currently lack antidote
- high cost
- not enough experience
if pt requires a single tooth extraction and takes Apixaban twice daily
how to go about
follow SDCEP guidance
- Evaluate and classify risk
* Refer to SDCEP – low risk of post-op bleeding complications (as simple extraction of single tooth) - Change drug regime as necessary
* Check guidance for alteration in drug scheduling – not needed as NOAC dose schedule changes is only needed in higher risk bleeding complication pts
if pt requires 4 teeth in lower right quadrant to be extracted and takes Apixaban twice daily - how to manage it
refer to SDCEP guidance
- Classify risk
- More than 3 teeth
- Flap raised
- higher risk of post operative bleeding
- Dose schedule
- Need changed as higher risk
- Takes twice daily – ask him to not take morning dose and take at usual evening time
- consult medical colleague
how to determine bleeding deficiency and severity if pt attends haemophilia centre
blood tests registered
haemophilia A
deficiency of factor VIII, most common (85% of all cases)
haemophilia B
deficiency of factor IX
difference between haemophilia A and B
Both forms are X-linked recessive conditions and can only be differentiated through coagulation factor assays
(A - VIII deficient, B - IX deficient)
severity of haemophilia
is a spectrum
- Severe = <1% factor present
- Moderate = 2-5% factor present
- Mild = 6-40% factor present
what could be causing this is pt who attends a hamophilia centre trips and falls into surgery
significant swelling of right knee
haemophilia and coagulation unit – alarm
- Manage issue swiftly – take priority over any dental Tx
Likely to be hemarthrosis
- Bleeding in joint space and is associated with haemophilia
- Damage to articular cartilage within the joint is common consequence of repeated hemarthrosis
- Intraosseous haemorrhage may lead to bone resorption and the development of bone cyst
clincal dx from radiograph
Periapical periodontitis 18, 26, 46, 47
Caries 18, 17, 27, 28, 47
Retained roots 26, 46 and 48
Chronic generalised periodontitis
haemophila considerations for dental care
Examinations and treatments that do not require manipulation of mucosa are safe to deliver to pts in this condition
Delivery of supragingival restorations, crowns and bridges with the use of infiltration anaesthesia is safe to provide for people with haemophilia in GDP
- dental extractions, surgical procedures, subgingival scaling or anaesthesia requiring IANB – need a dental clinic associated with haemophilia centre
- Increased risk of bleeding
- Require medical prophylaxis and monitoring
- Consider articaine infiltration and intraligamentary injection to avoid IANBs
- Increased risk of bleeding
DDAVP (desmopressin)
used in mild haemophila and von Williebrand’s disease
undertaken before dental procedures which inc bleeding risk
moderate and severe haemophila need before risk bleeding in dental procedure
factor replacment likely
mild haemophila and von williebrand disease before bleeding dental procedure
DDAVP (desmopressin) may be sufficient
factor replacement impact on dental tx plan
want to reduce the number of times any pt exposed to factor replacement
- Risk of local site infection
- Risk of inhibitors/ antibodies developing
- Cost
- Risk of blood borne infections if plasma derived factor is used although blood products are comprehensively screened
4 reasons why want to reduce number of times pt needs factor transfusion replacement
- Risk of local site infection
- Risk of inhibitors/ antibodies developing
- Cost
- Risk of blood borne infections if plasma derived factor is used although blood products are comprehensively screened
tranexamic acid
antifribrinolytic agent
can be used in management of haemophiliacs
dental factors to consider when building tx plan
- Previous dental experience
- Risk factors and potential for modification
- Oral hygiene and use of fluoride
tx should be in stages
short term
medium term
long term
short term tx plan should include
acute management - pain, swelling
prevention
stabilisation of disease
what to do if haemophiliac presents who has not been to centre for many years but requires tx due to facial swelling
not been tohaemophilia unit for many years – no up to date test results
Thus indicated to provide course antibiotics until appropriate assessments and planning can be made in conjunction with haemophilia unit
what should the approach to dentistry be if pt requires medical agent to be treated (e.g. platelet transfusion)
quadrant approach - do all tx in that quadrant that could cause bleeding risk (extractions, subgingival scaling etc)
minimise number of apps so need to for multiple exposures to medical agent
mid to long term tx plan should contain
prvention
re-evaluation of disease status (e.g. periodontal condition) and manage as required
restoration of spaces as needed
