Human Disease and Therapeutics Flashcards
7.1 a) When assessing an. Unwell pt we follow the ABCDE approach. What does each of these letters stand for?
i) Airway
ii) Breathing
iii) Circulation
iv) Disability
v) Exposure
7.1 b) Briefly describe how you would assess the A and B components in an unwell adult pt in your dental practice?
i) Airway
(1) If can speak, airway patent
(2) Partial obstruction = noisy breathing
(3) Complete obstruction = no breath sounds
(4) Obstruction lower airways =. wheeze on expiration
(5) Obstruction upper airways = stridor on inspiration
(6) Gurgling if liquid or semi solid in upper airway.
ii) Breathing
(1) Count respiratory rate, normal is 12-20 breaths per minute.
(2) Below 5 and above 35 is serious.
(3) Look at if chest is moving equally, depth and pattern of breathing.
(4) Pulse oximeter, can assess oxygen sats.
7.2 a) Briefly describe how you would assess the C, D and E components in an unwell pt in your dental practice.
i) Circulation
(1) Radial pulse of pt and assess rate and rhythm.
(2) Take blood pressure.
(3) Look at colour of pt’s hands and fingers for any signs of mottling, pallor or cyanosis.
(4) Assess capillary refill time by pressing on a fingertip held at level of heart for 5 seconds, which will cause it to blanch. The normal colour should return in 2 seconds. Longer implies a poor peripheral circulation.
(5) Warmth of hand, cold may imply poor circulation.
ii) Disability
(1) AVPU: A = alert, V = responds to verbal stimuli, P = responds to pain and U = unconscious.
(2) Blood glucose level.
(3) Examine eyes and assess size of both pupils and whether they react equally.
(4) Take what drugs/medicines pt takes.
iii) Exposure
(1) Look to see if there is a cause of the problem, e.g. bleeding or a rash.
7.3 a) What do you understand by the term immunocompromised?
i) Immunocompromised – the immune function of a patient is inherently poor. It can be suppressed artificially or depressed due to illness and they may be at risk of concurrent illness due to the reduced function of the immune system.
(acquired) conditions that cause a patient to be immunocompromised:
(1) Autoimmune: systemic lupus erythematosus (SLS)
(2) Chediak-Higashi syndrome
(3) Drug induced
(4) Human immunodeficiency virus (HIV)
(5) Leukocyte adhesion defect (LAD) 1
(6) Malignancies: leukaemias, Hodgkin’s disease
(7) Papillon-Lefevre syndrome
(8) Selective IgA disease
i) Primary conditions:
(1) Selective IgA disease
(2) Chediak-Higashi syndrome
(3) Papillon-Lefevre syndrome
(4) LAD1
ii) Secondary conditions:
(1) HIV
(2) Malignancies: leukaemias, Hodgkin’s disease
(3) Autoimmune, SLE
(4) Drug induced
7.3 b) Why might a patient be given immunosuppressive drugs?
i) Anti-rejection therapy for organ transplantation
ii) To treat autoimmune conditions
iii) To treat connective tissue disorders
iv) Control some lymphoproliferative tumours.
c) What are the oral signs that might present in an immunocompromised patient?
i) Mucositis
ii) Oral ulceration
iii) Xerostomia
iv) Opportunistic infections – bacterial, viral and fungal
v) Hairy tongue.
7.3 d) What tests would you want to carry out to determine a patient’s immune function prior to extraction of a lower molar?
i) You would check the levels of their white blood cells (WBCs) to ensure that they were able to resist infection if one occurred following the invasive procedure. Hence you would want to check the WBC count.
(1) Normal 4.5-10 x 10^9/L
(2) Differential white cell count:
(a) Lymphocytes 1-3.5 x 10^9 / L
(b) CD4 and CD8
(i) CD4 500-1500/mm^3
(ii) CD8 230-750/mm^3
(iii) Radio CD4:CD8 = 1.2-3.8
(c) Neutrophil count: 2.0 – 7.5 x 10^9
(d) Monocytes
(e) Eosinophils
(f) Basophils
7.4 a) What is the cause of Down syndrome?
i) A genetic condition caused by trisomy of chromosome 21.
7.4 b) Name 3 orodental features that a patient with Down syndrome may have.
i) Hypodontia/microdontia
ii) Delayed development and delayed eruption of both deciduous and permanent teeth.
iii) Hypocalcificiation/hypoplastic defects
iv) Early-onset periodontal disease
v) Gingivitis on anterior teeth due to mouth breathing.
vi) Anterior open bite, posterior crossbite and class III incisor relationship
7.4 c) What are the implications of Down syndrome on the delivery of oral healthcare.
i) Learning disability, although the degree varies from person to person.
ii) Cardiac abnormalities, some requiring surgical correction.
iii) Visual problems such as cataracts.
iv) Auditory problems due to fluid accumulation in middle ear.
v) Joints – atlanto-axial joint instability – do not hyper-extend neck.
vi) Compromised immune system – increased susceptibility to infections (bacterial/fungal/viral)
vii) Neurological conditions – epilepsy – management, drugs – gingival hyperplasia, sugar containing drugs, dry mouth.
viii) Alzheimer’s disease.
7.4 d) How would you gain consent from a patient with Down syndrome to carry out invasive dental treatment if the patient was aged 19?
i) Assess pt understand of issues to gain consent. If competent and understood everything, proceed as normal.
ii) MCA. Good practice to get agreement from the patient’s carers or family, but they cannot consent for them. Tx must be deemed in best interest for the patient.
(1) Pt presumed to have capacity until proven otherwise.
(2) Pt should not be deemed to lack capacity until all practical solution to help them to do so have been tried.
(3) An unwise decision does not mean a patient doesn’t lack capacity.
(4) Decision made under MCA must be in best interest of pt.
(5) If decision/action is done under MCA, must be done in a way that is less restriction of pts freedom of action.
7.5 a) What is the mechanism of action of the following autoimmune reactions?
(1) Type I, Type II, Type III, Type IV
ii) Type I = Immediate hypersensitivity (anaphylaxis, allergic asthma, allergic rhinitis). Mediated by IgE.
iii) Type II = Antibody dependent (transfusion reactions, myasthenia gravis)
iv) Type III = Immune complex (rheumatoid arthritis, systemic lupus erythematosus)
(1) Mediated b
v) Type IV = cell mediated (contact dermatitis, pemphigoid, Hashimoto thyroiditis).
7.5 b) What signs and symptoms might a patient experiencing a type 1 reaction show?
i) Rash, itching, facial flushing, tingling of face, swelling of tongue, wheeze, stridor, collapse
7.5 c) Latex allergy is common in the general population. Name six items in a dental surgery that contain latex.
i) LA cartridges, gloves, rubber dam, mouth props, blood pressure cuffs, orthodontic elastics, mixing bowls, endodontic stops.
7.6 What type of drug is warfarin and what is its mode of action?
i) It is an anticoagulant, and it is a vitamin K antagonist.
7.6 b) How is warfarin treatment monitored?
i) By measuring a patient’s INR (international normalised ratio), which is the ratio of patient’s prothrombin time to control prothrombin time.
7.6 c) List three medication conditions for which patients may be prescribed warfarin?
i) Atrial fibrillation
ii) Prosthetic heart valves
iii) Deep vein thrombosis
iv) Pulmonary embolism
v) Cerebrovascular accident
vi) Antiphospholipid syndrome.
7.6 d) Which of the following drugs may interact with warfarin? Do they enhance or decrease the action of warfarin?
(1) Fluconazole, penicillin, metronidazole, adrenaline, paracetamol, carbamazepine.
i) Fluconazole and metronidazole = enhances anticoagulant effect.
ii) Carbamazepine = reduces anticoagulant effect.
b) What type of drug is tranexamic acid? How is it administered and when would it be used?
i) It is an antifibrinolytic agent, inhibits formation of plasmin from plasminogen. . It may be used topically as a mouthwash or by soaking swabs in it and getting the patient to bite on them. It can also be given orally or intravenously. It is used to prevent and control bleeding especially during and after the procedure.
7.7 a) What are the dental implications of the following findings in a patient’s medical history: The patient is taking glyceryl trinitrate (GTN).
i) GTN is a vasodilator and also reduces left ventricular work by reducing v venous return. Hence it is used to provide symptomatic relief in angina. Angina occurs when there is an imbalance between the demand and supply of blood to the heart and the patient experiences crushing central chest pain that can radiate down the left arm. An attack may be precipitated by dental treatment. Reducing stress by providing good anaesthesia and not subjecting pts to loo long appointments will minimise the likelihood of the patient having an attack. In addition, the patient should take GTN at the start of an appointment.
7.7 b) What are the dental implications of the following findings in a patient’s medical history: Pt is taking Insulatard
i) Insulatard is an insulin preparation that is used to control the blood glucose levels in patients with insulin-dependent diabetes mellitus. Patients self-administer Insulatard subcutaneously. Diabetic patients have poor wound healing and are more susceptible to infections. Hence they are prone to gingivitis, rapidly progressing periodontal disease and oral candidal infections. They may also have xerostomia. Treatment should be timed so that it does not interfere with the meal times as hypoglycaemia may develop and the patient may collapse.
7.7 c) What are the dental implications of the following findings in a patient’s medical history: Pt is taking nifedipine
i) Nifedipine is a calcium-channel blocker used to treat hypertension. Hypertensive patients are at increased risk of other cardiovascular disease. Routine dental treatment may need to be postponed if the patient’s blood pressure is greater than 160/110mmHg. Hypertensive patients are more likely to have excessive bleeding following extractions. Nifedipine can cause gingival hyperplasia.
d) What are the dental implications of the following findings in a patient’s medical history: The patient has had infective endocarditis in the past but is not allergic to penicillin
i) Pts who have had previous infective endocarditis are no longer routinely given antibiotic cover prior to dental treatment. It is though that maintaining a good standard of oral hygiene and dental health is more important as bacteraemia can occur following chewing and tooth brushing and not just invasive dental treatment.
e) What are the dental implications of the following findings in a patient’s medical history: The patient has osteoporosis and is taking bisphosphonate tablets (Fosamax 70mg) once a week.
i) Pts who take bisphosphonates are at greater risk of getting medication-related osteonecrosis of the jaws (MRONJ). This may arise spontaneously or following dental treatment, especially extractions. In terms of dental tx it is important to make sure that dentures fit well and are relined if necessary as trauma may lead to MRONJ. Routine dental tx can be carried out with little likelihood of risk. Extractions may cause MRONJ, however, the risk is very low, and hence it may be advisable to restore teeth rather than extract if possible. If extractions cannot be avoided then patients should be informed about the risk when consent is to be gained and it may be advisable to give the patient pre- and post- operative chlorhexidine mouthwash. It may also be advisable to limit extracts to one quadrant at a time and wait for sockets to heal fully before moving on to the next quadrant.
7.8 a) Which drug, dose and route should be used in the emergencies listed below?
(1) Anaphylaxis
(2) Hypoglycaemic collapse
(3) Status epilepticus
(4) Myocardial infarction
(5) Asthmatic attack
i) Anaphylaxis
(1) Epinephrine, 0.5ml of 1:1000 adrenaline, intramuscular.
ii) Hypoglycaemic collapse
(1) Oral glucose if conscious
(2) Glucagon, 1mg, intramuscular injection if unconscious.
iii) Status epilepticus
(1) Midazolam, 10mg (2ml oromucosal solution 5mg/ml), buccal
iv) Myocardial infarction
(1) Glyceryl trinitrate, 2 puffs (400 micrograms per metered dose), sublingual
(2) Oxygen (15L/min)
(3) Aspirin 300mg dispersible tablet, orally.
v) Asthmatic attack
(1) Salbutamol, 4 puffs (100 micrograms per actuation) through large volume spacer.
7.9 a) What do the following terms mean? Give an example of each.
(1) Autograft
(2) Allograft
(3) Xenograft
i) Autograft = from the same person
(1) Iliac crest to jawbone
ii) Allograft = from an individual of same species
(1) Kidney, liver, cornea, heart, lung.
iii) Xenograft = from a different species.
(1) Porcine heart valves
7.9 b) Many patients who receive transplants are on immunosuppressant medication. What are the side-effects of immunosuppressant medication?
i) Increased risk of infection
ii) Increased risk of cancer (skin and haematological).
7.9 c) Ciclosporin is a commonly used immunosuppressant drug. Name a complication that may occur with its use.
i) Gingival hyperplasia
ii) Diabetes
iii) Hypertension
7.9 d) Name another commonly used immunosuppressant drug.
i) Azathioprine
ii) Mycophenolate mofetil.
7.10 What are the major systemic side-effects of steroids? List four the systems that may be affected and give two examples
i) Gastrointestinal – peptic ulceration, dyspepsia, oesophageal candidal infection
ii) Musculoskeletal – proximal myopathy, osteoporosis, vertebral and long bone fractures.
iii) Endocrine – adrenal suppression, Cushing’s syndrome, hirsutism, weight gain, increased appetite, and increased susceptibility to infections.
iv) Neuro-psychiatric – mood changes, depression, euphoria, psychological dependence psychosis.
v) Eye – glaucoma, increased intraocular pressure.
vi) Skin – skin atrophy, telangiectasia, bruising and acne.
7.10 b) Name an oral condition for which a patient may be prescribed topical steroids.
i) Recurrent aphthous ulceration
ii) Lichen planus
7.10 c) Name a head and neck condition for which a patient may be prescribe systemic steroids.
i) Bell’s palsy
ii) Giant cell arteritis
iii) Pemphigoid
iv) Pemphigus
v) Sarcoidosis
7.11 a) What causes HIV disease?
i) HIV disease is caused by infection with human immunodeficiency viruses and RNA retroviruses
7.11 b) How does it spread?
i) Sexually, through blood and blood products, intravenous drug misuse, vertical transmission from mother to child.
7.11 c) What part of the immune response is affected?
i) T cell mediated immunity, in particular, CD4-positive lymphocytes.
7.11 d) Name 5 oral conditions/lesions strongly associated with HIV disease.
i) Candida infections
ii) Oral hairy leukoplakia
iii) Kaposi sarcoma
iv) Periodontal disease (gingivitis and periodontitis)
v) Non-Hodgkins lymphoma
vi) Necrotising ulcerative gingivitis
vii) Ulcers
7.11 e) What types of drug are used to treat HIV disease?
i) Nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors.
ii) Protease inhibitors.
7.11 f) What is the importance of HIV for a dentist?
i) There is a risk of cross-infection. The patient is immunocompromised and hence may be more susceptible to infection than a healthy patient. They would be on multidrug treatment.
7.12 a) How is liver disease relevant to dentistry?
i) Patients with liver disease may have excess bleeding because of abnormal clotting factors.
ii) Patients with liver disease may be unable to metabolise drugs normally.
iii) Patients with liver disease may have a transmissible disease that could be a potential cross-infection risk.
iv) Patients may have delayed healing due to hypoproteinaemia and hence immunoglobulin deficiency.
v) Administration of intravenous sedation may result in coma.
7.12 b) How are the following diseases spread? : Hepatitis A Hepatitis B. Hepatitis C. Hepatitis D
i) Hep A: oro-faecal
ii) Hep B: parent, sexually, perinatally.
iii) Hep C: parent, sexually, perinatally.
iv) Hep D: parent, sexually, perinatally.
7.12 c) What infective agent causes Hepatitis B?
i) A DNA virus called hepatitis B virus.
7.12 d) Which type of hepatitis can people be vaccinated against?
i) A and B
7.12 e) Which type of hepatitis must all dental personnel be vaccinated against? What type of vaccine is used?
i) Hepatitis B. Recombinant DNA hepatitis surface antigen (HbsAg).
7.13 a) Match the drug with the appropriate statement.
(1) Aciclovir
(2) Amphotericin
(3) Benzyl penicillin
(4) Co-amoxiclav
(5) Clindamycin
(6) Metronidazole
(7) Phenoxymethylpenicillin
(8) Vancomycin
(a) Inactivated by gastric acid and is best given by infections.
(b) Active against many streptococci
(c) Active against B-lactamase producing bacteria as it contains clavulanic acid.
(d) May cause pseudomembranous colitis.
(e) Associated with ‘red man’ syndrome
(f) Active against anaerobes
(g) Is a polyene antifungal drug
(h) Can be used to treat herpes simplex infections.
i) Aciclovir = Can be used to treat herpes simplex infections
ii) Amphotericin = Is a polyene antifungal drug
iii) Benzyl penicillin = Inactivated by gastric acid and is best given by infections.
iv) Co-amoxiclav = Active against B-lactamase producing bacteria as it contains clavulanic acid.
v) Clindamycin = may cause pseudomembranous colitis.
vi) Metronidazole = active against anaerobes
vii) Phenoxymethylpenicillin = active against many streptococci
viii) Vancomycin = associated with ‘red man’ syndrome
b) Give four indications of systemic antibiotics in dentistry.
i) Spreading infection = cellulitis, swelling, lymphadenopathy, trismus
ii) Systemic infection = pyrexia, malaise.
iii) Prevention of postoperative infection.
iv) Antibiotic cover to prevent infection in patients with IE risk when appropriate.
v) Prevention of infection following oral and maxillofacial trauma.
7.14 a) What do you understand by the term anaemia?
i) Anaemia is a reduction in the oxygen-carrying capacity of the blood. IT is defined by a low value for haemoglobin (females <115 g/L and males <135 g/L).
