Haematology Tutorial Flashcards
What are local factors that cause oral candidiasis?
Antibiotic use, dentures, local corticosteroid use, xerostomia (drug induced or radiotherapy induced).
What are general factors that cause oral candidiasis?
Drugs, extremes of age, endocrine (Cushings and diabetes mellitus), immunodeficiency (hereditary or acquired), iron deficiency and smoking.
What are risk factors for periodontitis?
Smoking, alcohol, poor oral hygiene, diabetes, dry mouth, poor diet and nutrition etc.
What is atrial fibrilation?
Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate.
What complications can occur as a result of atrial fibrilation?
Can result in complications such as: pulmonary embolism (PE); deep vein thrombosis (DVT); cerebro- vascular accident (CVA/stroke), and myocardial infarction (heart attack/MI).
How can diabetes be related to oral health?
- Risk of hypoglycaemic episode – medical emergency
- Periodontal Disease
- Delayed healing
- Salivary gland dysfunction
- Oral dysesthesia.
What is hypertension a risk factor of?
Heart disease, Heart attacks, Strokes, Heart failure, Peripheral arterial disease, Aortic aneurysms, Kidney disease, Vascular dementia.
What is warfarin?
It is a vitamin K antagonist. Warfarin blocks the liver from using vitamin K to make clotting factors. This thins your blood, so it takes longer to clot.
What is NOAC?
The novel oral anticoagulants (NOACs) are a new class of anticoagulant drug. They can be used in the prevention of stroke for people with non-valvular AF, which is when AF is not associated with a problem in a heart valve. INR does not need checked with these drugs.
What is simvastatin for?
HMG CoA reductase inhibitors and are used to treat hypercholesterolaemia. This group of drugs may have interactions with other medications you can prescribe as a dental practitioner.
What is furosemide used for?
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, there is less risk of hyperglycaemia when compared to the use of the thiazide diuretics.
What is carvediol used for?
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.
Individuals who are medicated with non-selective beta blockers have a heightened sensitivity to the effects of vasopressors present in local anaesthetics. This can result in an increase in vascular resistance with a subsequent increase in blood pressure. There are reports in the medical literature of MI and stroke occurring as a consequence. This risk is small in the practice of dentistry and can be prevented with appropriate drug selection and local anaesthetic technique.
What appointment time is the best for a diabetic individual?
We should consider timing appointments to ensure his blood glucose levels are appropriate for treatment and do not coincide with time of peak insulin activity as this presents the greatest risk for hypoglycaemia.
What is metformin used for?
Metformin hydrochloride has an anti-hyperglycaemic effect.
Metformin hydrochloride is recommended as the first choice for initial treatment for all patients with diabetes, due to its positive effect on weight loss, reduced risk of hypoglycaemic events and the additional long-term cardiovascular benefits associated with its use.
Why is hypertension needed to be controlled within dentistry?
It is important we firstly establish the stage of this gentleman’s hypertension. A hypertensive crisis (>180/110) is a medical emergency. Uncontrolled hypertension may need to be controlled before the delivery of dental treatment. If dental anxiety is a trigger for significant and dangerous increases in blood pressure it may be valuable to consider the role of sedation.
What diabetic test measures the patients last 3 months of sugars?
HBIAC test.
What is the relevance of warfarin in dentistry?
Prior to providing any dental treatment it would be valuable to understand what this gentleman’s bleeding risk is.
This can be established through a special investigation. The INR is the test of relevance to dental practitioner. This will allow us to assess this gentleman’s bleeding risk and warfarin control.
It is possible to provide some treatment for Mr Fraser today. You could provide him with the initial preventative messages that are essential to the long-term maintenance of oral health.
Depending on how much information is available to you today will determine whether you are able to proceed with any operative care.
How can dentists manage oral candidiasis?
Candida exist in a biofilm. Therefore, initially we should observe the principles of biofilm management and consider mechanical disruption. Additionally, it should be noted that there is an increase in the resistance profile of candida species to drug therapies.
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. Candida species can 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 medications 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 contraindicated 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.
What is an INR?
An INR is a type of blood test and it is particularly useful for monitoring individuals taking the medication warfarin.
The INR is a ratio. It is calculated by taking the prothrombin time (PT – time for plasma to clot) of the patient and dividing it by a reference PT plasma value which has been corrected for the thromboplastin used in the test.
INR = PT / Reference PT Plasma
The INR value of a normal healthy individual should be 1.
For patient prescribed warfarin, there are target ranges in which the patient’s INR should sit.
How close to the appointment do you want an INR text to be done if the patient is taking warfarin?
We have not previously met this individual. If we had access to his INR results we could assess the level of control of his medication and assess the risk of undertaking any procedures. We can access this information through digital medical records or in a more traditional setting in a yellow book which the patient may carry.
If we take everything into account about this gentleman including his poor control of diabetes, his multiple risk factors for a number of diseases it would seem sensible to obtain an INR at least 24 hours prior to providing any care for him.
It is always sensible to fully evaluate a patient prior to undertaking any operative care. Whilst guidelines classify risk and discuss safe procedures, it would always be good practice to fully assess and evaluate each patient.
What INR does a warfarin patent need in order to get a tooth taken out?
The INR value today is 4. The SDCEP guidelines state that the INR level should be less than 4 for a tooth to be removed safely.
