Medical history Flashcards
1
Q
Cardiac conditions associated with the higher risk of Infectious Endocarditis for which prophylactic antibiotic with dental procedures is recommended
A
According to the current AHA guideline in 2021,
prophylactic antibiotics are recommended
1. prosthetic cardiac valve or material
2. previous or recurrent infectious endocarditis
3. congenital heart disease
4. cardiac transplantation recipient who develops cardiac valvulopathy
- Prophylactic abx is not suggested for pacemaker, hemodialysis, coronary artery stent.
2
Q
Dental procedures in pts with cardiac condition for which IE prophylaxis is recommended
A
All dental procedures that involve manipulation of 1. gingival tissue or 2. periapical tissue or 3. perforation of the oral mucosa
3
Q
What is the most common pathogen identified in IE?
A
Staphylococci are the most common pathogen identified in IE, accounting for 30~35% of infections.
4
Q
Prophylactic ABX after prosthetic joint replacement
A
Prophy ABX before RCT is not indicated for healthy pts after prosthetic joint replacement. However, during the first 3mo after joint operations, ABX prophylaxis should be considered (Segura-Egea).
5
Q
Prophylactic ABX for pts receiving dialysis
A
Current AHA guideline recommends prophylactic antibiotics if abscess is present and is being incised and drained
- does not recommend prophy ABX before invasive dental procedures.
6
Q
Management of pts with prosthetic joints undergoing dental procedures
A
2015 ADA and American Academy of Orthopedic Surgeons guidelines
The current recommendation is that “ in general, pts with prosthetic joints are not recommended to receive prophylactic antibiotics before dental tx.”
For pts with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the pt and orthopaedic surgeon.
Most prosthetic joint infections are caused by Staphylococcus aureus, which is not normally found in the mouth.
7
Q
Classification of Blood Pressure in adults
A
normal 120/80
elevated 120-129 or <80
stage 1 HTN 130-139 or 80-89
stage 2 HTN 140/90 - 180/110
(>=140 or >=90)
uncontrolled HTN >180/110
HTN emergency >180/120
8
Q
Dental management based on blood pressure
A
Pts with BP < 180/110 may receive any necessary dental tx; consider BP monitoring during tx for stage 2 HTN (140/90-180/110).
Pts with a BP >180/110 (severely uncontrolled HTN) should defer elective tx.
9
Q
Causes of hypertension
A
chronic kidney disease
chronic steroid therapy
hyperthyroidism
sleep apnea
10
Q
Chlorothiazide (Diuril), Hydrochlorothiazide (HCTX)
Furisemide (Lasix), Bumetanide (Bumex)
Amiloride (Midamor)
A
diuretics
inhibits sodium reabsorption
1. avoid NSAIDs - may reduce antihypertensive effects
long-term (>2wks) use of NSAIDs may interfere with effectiveness of antihypertensive medications (diuretics, beta-blocker, ACE blocker, alpha 1 adrenergic blocker, direct vasodilator)
2. vasoconstrictor interactions - none
11
Q
Propranolol (Inderal)
A
nonselective beta blocker
block adrenaline -> reduce heart rate
1. avoid prolonged use of NSAIDs - may reduce antihypertensive effects
2. drug interaction with epinephrine - potential increase in BP (use maximum of 0.036mg of epi)
12
Q
Lisinopril
A
Angiotensin-Converting Enzyme (ACE) inhibitors
block the conversion of angiotensin I to II -> prevent angiotensin II that narrows blood vessels
1. avoid NSAIDs - may reduce antihypertensive effects
2. vasoconstrictor interaction - none
13
Q
Losartan, Valsartan
A
Angiotensin II Receptor Blockers
prevent angiotensin II binding
14
Q
Amlodipine (Norvasc), Nifedipin
A
Calcium Channel Blockers
block calcium influx in heart, vascular smooth muscle
1. gingival overgrowth
2. avoid macrolide abx (erythromycin, clarithromycin, not azithromycin) - can raise plasma levels of CCBs resulting in hypotension
15
Q
Doxazosin (Catapres), Terazosin (Hytrin)
A
alpha1-adrenergic blockers
inhibit smooth muscle contraction
1. avoid NSAIDs - may reduce antihypertensive effects
2. vasoconstrictor effect - none
16
Q
Clonidine (Catapres), Methyldopa (Aldomet), Reserpine
A
alpha2-adrenergic agonists
17
Q
Hydralazine, Minoxidil (Loniten)
A
direct vasodilators
1. avoid NSAIDs - may reduce antihypertensive effects
2. vasoconstrictor effect - none
18
Q
HTN - antibiotics
A
Avoid erythromycin, clarithromycin (not azithromycin) with CCBs because the combination can enhance hypotension
19
Q
HTN-anxiety
A
- Use stress reduction protocol
- Consider the use of pre-op oral sedation (short-acting benzodiazepine 1hr before procedure)
- Consider the use of N2O inhalation sedation intraoperatively (Stanley - 30~50% N2) sedation sig increase in the success of IAN block
20
Q
HTN-anesthesia
A
- Ensure profound LA
- Avoid excessive amounts of epi in pts who take nonselective beta blockers, which can cause a spike in BP and appears to be dose dependent
- Limit to 2 carpules of 1:100K epi (0.04mg)
21
Q
HTN-BP
A
For pts with starge 2 HTN (BP>140/90), periodic BP monitoring during tx may be advisable.
22
Q
HTN-capacity to tolerate care
A
Pts with HTN <180/110 may receive routine dental care.
BP>180/110 defer elective treatement
BP>180/120 is HTN emergency.
23
Q
orthostatic hypotension
A
postural hypotension - dizzy, faint
BP drops when stranding from sitting or lying down
24
Q
HTN-chair position
A
- Avoid rapid position changes d/t possibility of antihypertensive drug-associated orthostatic hypotension.
- After the procedure, allow pt to sit in upright for several mins before dismissing to avoid dizziness.
25
HTN-drug
Avoid long-term (>2wks) use of NSAIDs because these agents may interfere with effectiveness of antihypertensive drugs.
26
HTN crisis management
activate EMS
monitor vital signs
sublingual nitroglycerin
nasal oxygen
aspirin
provide CPR, use AED, if needed
27
AHA antibiotics regimes for dental procedures
1. oral
2. unable to take oral meds
3. allergic to PCNs
4. allergic and unable to take oral meds
1. AMX 2g
2. Ampicilline 2g IM/IV
Cefazolin or Ceftriaxone 1g IM/IV
3. Azithromycine or Clarithromycin 500mg
Doxycycline 100mg
4. Cefazolin or Ceftriaxone 1g IM/IV
* Caphalosporins should not be used in an individuals with a history of anaphylaxis, angioedema, or urtecaria with penicillne or ampicillin
28
Etiology of Diabetes Mellitus
1. Lifestyle - increased BMI
obese: BMI >25, >23 in Asian Americans
2. Environmental factors
3. Genetic predisposition - a number of susceptible variants have been identified
29
Types of DM
Type I - pancreatic beta-cell destruction, insulin deficiency
sudden onset, autoimmunie
Type II - insulin resistance, relative insulin deficiency
occurs over age 40
Gestational Diabetes - abnormal glucose tolerance
diagnosed in the 2nd and 3rd trimester
30
Risk factors of DM
1. Obese - BMI>25, BMI>23 in asian-americans
2. physical inactivity
3. high-risk of race/ethnicity
African american, Native american, Asian american, pacific islander
4. first-degree relative with diabetes
5. hypertension BP>140/90
6. history of cardiovascular disease
31
DM oral complications and manifestations
1. poor glycemic control and associated dehydration
2. xerostomia
3. increased glucose concentration in saliva
4. increased incidence of caries
5. periodontal disease
6. altered response to infection
7. bacterial, viral, fungal infection (candidiasis)
8. poor wound healing
9. microvascular change
10. diabetic neuropathy may lead to tingling, numbness, pain
32
DM-prophy abx
prophy abx - not required
poorly controlled DM, FBG>200 + invasive procedure = abx may be given in post-op setting
33
DM-anesthesia
no issues if diabetes is well-controlled
For DM pts with cardiovascular comorbities (HT, recent MI), avoid high amount of epi
34
DM-anxiety
anxiety may impact glycemic control and trigger hypoglycemia
35
Instruction to DM patients
advise to take medications/usual insulin dosage and normal meals on day of dental appointment
36
DM pts on day of appointment
1. check chairside glycemic values
use office glucometer to ensure adequate glucose control
2. have glucose source available if needed
37
DM-post-op analgesia
Aspirin, NSAIDs, tramadol - increase risk for hypoglycemia
* Aspirin, NSAIDs (highly bound to plasma protein, may displace sulfonylureas, glinides)
Opioid - risk for hyperglycemia
38
When do DM pts undergo dental, surgical procedure?
Diabetes with no significant comorbities & a pre-op FBG btw 80 and 200 can safely undergo dental, surgical procedure
= Pts with well-controlled diabetes without severe comorbities (HT, coronary artery dis, renal dis) require no special attention when receiving routine dental tx.
-> Pts with FBG below 70 and above 200 are at a higher risk for hypoglycemia (give carb) and post-op complications (give hypoglycemic or insulin)
39
Hypoglycemia - signs and management
Mild stage - hunger, tarchycardia, sweating, pallor
Moderate - uncoorperativeness, poor orientation
Severe - unconsciousness, tonic or clonic movement
give the conscious pts fruit juice or cake icing
for pts in the severe stage, treat with an IV glucose; glucagon or epinephrine may be used for transient relief
40
Pts with DM and acute odontogenic infections
1. non-insulin controlled pt
- consult with physician, may require additional insulin
2. Insulin
- increased dosage of insulin, consult
3. poorly controlled, high insulin dosage
- culture, abx sensitivity testing
4. 1) I&D 2) pulpotomy, pulpectomy, Ext 3) ABX 4) warm intraoral salt water rinse
41
What are three categories of adrenal insufficiency?
Primary AI - Addison disease
Secondary AI - pituitary disease
Tertiary AI - most commonly caused by chronic use of corticosteroids. Prolonged corticosteroid use suppresses the hypothalamic-pituitary axis (HPA).
42
Primary adrenal insufficiency - steroid supplementation
Glucocorticoid replacement is accomplished at levels that correspond to normal physiologic output of the adrenal cortex, 20~25mg/day of hydrocortisone.
Target dose levels during periods of stress
Steroid supplementation during surgery
Minor surgery - 25mg of hydrocortisone equivalent
Moderate - 50~75mg
Major - 100~150mg
43
Tertiary adrenal insufficiency - steroid supplementation
Previous recommendation - "at-risk" pts who take corticosteroids should be provided supplemental steroids during periods of stress, trauma, or illness -> revised
Current recommendation - only pts with primary AI receive supplemental doses of steroid
Majority of pts who take daily equivalent or lower doses of steroid (mean dose of 5~10mg/day of prednisone) on a long-term basis for rheumatoid arthritis maintain adrenal function and do not experience adverse outcome after surgery.
44
When do we use synthetic glucocorticoids and how they affect systemically?
used in the treatment of autoimmune and inflammatory diseases. they may affect adrenal function
supra-physiologic dosage (10~20mg prednisone), more than 2weeks
45
Features of Adrenal Crisis
Tx, Risk assessment
Adrenal crises are triggered by emotional and physical stress (infection, fever, during or after surgery) when the body is unable to meet the increased demand for cortisol.
Signs - sweating, weakness, fever, hypotension (If BP drops below 100/60mmHg, consider fluid replacement and supplemental steroid administration), dehydration
Tx -
activate EMS
monitor vital signs
apply ice packs
start IV saline (fluid and electrocyte replacement)
IV hydrocortisone 100mg
Risk assessment
- adrenal crisis is more likely in pts with AI who have malignancy, major traumatic injury, severe pain, infection, liver cirrhosis
46
Dental management of pts with possible AI
1. analgesics
2. ABX
3. anesthesia
4. anxiety
5. Bleeding, BP
1. Analgesics - provide good post-op pain control to avoid adrenal crisis
2. ABX - no issues
3. Anesthesia - routine use of epi is appropriate. consider using long-acting LA (bupivacaine) at the end of procedure to provide longer post-op pain control
4. Anxiety - anxiety and stress increase the risk of adrenal crisis if AI is present, use anxiety and stress reduction techniques.
5. Bleeding -minimize blood loss
5. BP - continuously monitor BP. If BP drops below 100/60mmHg, consider fluid replacement and supplemental steroid administration.
47
Dental management of pts with possible AI
6. capacity to tolerate care
7. drugs
8. emergency
9. follow-up
6. Capacity to tolerate care - Pts who have AI are potentially at risk for an adrenal crisis. Currently, only pts with primary AI are recommended to receive corticosteroid supplementation, and this recommendation applies only for surgery or in case of dental or systemic infection.
7. Drugs - provide steroid supplementation for primary AI during surgery or infection. avoid phenobarbital, phenytoin, ketoconazole at least 24h before surgery
8. Energency - call 911, apply ice packs, monitor vital signs, start IV saline solution, inject 100 IV of hydrocortisone
9. F/U - AI pts should be monitored for good fluid balance and adequate BP during the first 24h postsurgery.
48
What should be considered for pregnant patients?
1. supine hypotensive syndrome - late 3rd trimester
2. gestational diabetes
3. pregnancy gingivitis - pyogenic granuloma, pregnancy tumor
4. drug-related issues
5. dental radiography during pregnancy
49
What is the concern in dental treatment for pregnant patient in late 3rd trimester?
supine hypotensive syndrome
risk of thromboembolism
50
Discuss supine hypotensive syndrome
Sudden drop in BP when the pt is in supine position
Cause - impaired venous return to the heart that results from compression of inferior vena cava
Tx - roll the pt over onto her left side
51
What is gestational diabetes?
Abnormal glucose tolerance diagnosed in the 2nd and 3rd trimester. 2~6% of pregnant women
Insulin resistance is a contributing factor to the development of GDM.
GDM increases the risks for infection and large birth weight babies.
52
Risk factors of gestational diabetes
high BP
Cardiovascular dis
family history of type 2 DM
obese BMI>25
polycystic ovary syndrom
53
What is a common periodontal disease during pregnancy?
pregnancy gingivitis
pyogenic granuloma or pregnancy tumor
54
Cause of pregnancy gingivitis
increased secretion of estrogen & progesterone and altered fibrinolysis -> exaggerated inflammatory response to local irritants
prevotella intermedia
55
Sign and symptoms of pregnancy gingivitis
Pregnancy gingivitis begins at the marginal and interdental gingiva, in the second month of pregnancy
-> progresses to pyogenic granuloma or pregnancy tumor - edematous interdental papilla
Tx. surgical or laser excision if symptoms, bleeding
56
Treatment timing during pregnancy
First trimester (1-12wks) - urgent care only
Second trimester (13-28wks) & early part of the third trimester - stable to provide routine dental care
after the mid-third trimester (29-40wks) - defer elective care
57
Analgesics - pregnancy
Acetaminophen - the drug of choice
Aspirin/NSAIDs
-> Risks for constriction of ductus arteriosus, postpartum hemorrhage, delayed labor when administered during the third trimester
avoid Opioids - congenital defects
58
Antibiotics - pregnancy
FDA classification A or B
AMX, cephalosporin, metronidazole, clindamycin, erythromycin
avoid tetracycline - Tc bind to HA, causing brown discoloration
59
Anxiety - pregnancy
avoid Benzodiazepine
a single, short term use of N2O for less than 30mins is considered safe
60
Anesthesia - pregnancy
Lidocaine, prilocaine with epinephrine - safe during pregnancy
61
N2O guidelines during pregnancy
1. use of N2O should be minimized to 30min
2. at least 50% oxygen should be delivered at all times
3. appropriate oxygenation should be provided at the termination of administration
3. the second and third trimester are safer periods for treatment
62
How can you explain the risk of dental radiography during pregnancy?
1. The maximum risk from 1 centigrade of radiation exposure during pregnancy (which is equivalent to more than 1,000 FMX) is 0.1%. This is thousands of times lower than the usual risks of miscarriage, birth defects, or genetic disorders.
2. The radiation from 2 PA x-rays (with a lead apron) is 700 times less than what you get from natural background.
63
Reduction of radiation dose to pregnant pts
ALARA (as low as reasonably achievable)
use of lead apron
rectangular collimation
E-speed film or faster technique
-> one or two intraoral films are minute radiation effects on a developing fetus
64
Osteoporosis medications and MOA
1. bisphosphonate (Fosamax, alendronate; boniva; zometa, zolendronate)
- inhibits bone resorption through induction of osteoclast apoptosis
2. denosumab
- RANKL inhibitor -> inhibits Oc formation
65
Risk of MRONJ
oral bisphosphonate <0.01%
IV bisphosphonate 2~4%
66
Risk assessment of patients who have HIV
How can we gauge disease control and immunosuppression?
HIV viral load, CD4 lymphocyte count, complete blood count (CBC)
Patients with CD4+ cell counts <200 cells/mm3 are profoundly immunosuppressed and at increased risk for opportunistic infections as well as neutropenia (WBC<2,000, neutriphil<500), thrombocytopenia (platelet<50,000).
67
What complications may patients with HIV/AIDS face during dental treatment?
Patients with HIV/AIDS may be at risk for complications such as 1. infection, 2. bleeding, 3. drug interactions, and side effects during dental treatment.
68
HIV - analgesics
Drug interaction of ARV with below drugs:
Aspirin, NSAIDs
opioid
diazepam
TCA
carbamazepine
69
Medical management of HIV-infected patients
HAART stands for Highly Active AntiRetroviral Therapy.
Treatment that uses a combination of three or more drugs to treat HIV infection.
Introduction of HAART has turned HIV infection into a chronic disease.
HAART can suppress viral load to undetectable level and reduces the risk of opportunistic infections.
70
occupational risk of HIV infection
0.3%
PrEP (Preexposure ARV prophylaxis)
71
How can we gauge disease control and immunosuppression?
Disease control and immunosuppression may be measured by viral load, CD4 lymphocyte count, CBC
72
Head, neck, and oral lesions and conditions associated with HIV infection and AIDS
persistent generalized lymphadenopathy
oral candidiasis
HIV-associated gingival or periodontal disease
Herpes simplex virus infection
Varicella-zoster virus infection
oral hairy leukoplakia
Kaposi sarcoma
Lymphoma
73
Oral complication that may occur in association with HIV infection
Candidiasis (most common), gingival & periodontal disease, NUG, NUP
herpes virus infections, recurrent aphthous ulceration, malignant neoplasm
74
Four categories of hypersensitivity reactions
Type 1 - IgE mediated hypersensitivity
1) atopy - asthma, urticaria, angioedema
2) anaphylaxis
Type 2 - IgG or IgM mediated cytotoxic hypersensitivity
transfusion reaction
Type 3 - immune-complex mediated hypersensitivity
aphthous stomatitis
drug allergy (sulfa, sulfonylurea) - erythema multiform
Type 4 - delayed cell mediated hypersensitivity
material (amalgam), latex
75
Signs and symptoms suggestive of an allergic reaction
urticaria, swelling, skin rash, chest tightness, difficulty breathing
76
Adverse reactions of LA
1. allergic reaction - procaine, sulfite in epi
2. anxiety (syncope)
3. CNS stimulation -> CNS depression -> toxicity
4. epinephrine reaction - vasoconstrictor effect
77
penicillin hypersensitivity
cephalosporin
78
Aspirin - allergy
Aspirin provokes a severe reaction in some pts with asthma
79
NSAIDs contraindication
pts with an ulcer or hemorrhagic disease, pregnant, and pts with chronic renal dis
1. diuretic, beta blocker, ACE blocker, alpha 1 adrenergic blocker, direct vasodilator
2. warfarin
3. DM
4. pregnancy 3rd trimester
5. Asthma
6. Liver cirrhosis
7. gastrointestinal disease
8. kidney
9. cholinesterase inhibitor
80
Type I hypersensitivity - oral complications and management
urticarial swelling or angioedema
- occurs soon after contact, remain for 1~3days
- painless swelling, itching burning
Tx
- 50mg diphenhydramine 4 times/day until swelling diminishes
- 0.3-0.5mL 1:1000 epi, IM or SC
- oxygen
81
Angioedema management
If an immediate type I hypersensitivity reaction results in edema and pt is in acute respiratory distress,
- activate EMS
- inject 0.3-0.5 mL of 1:1000 epi IM or SC
- IV diphenhyramine 50-100mg
- support respiration
- check the carotid pulse; if not detected, initiate CPR
82
Type III hypersensitivity
white, erythematous, ulcerative lesions
develops within 24hr
Erythema multiforme - drug allergy (Sulfa antibiotics, Sulfonyl urea hypoglycemic agents) or herpes simplex infection
Tx
- diphenhydramine, corticosteroids
83
Anaphylaxis management
- activate EMS
- monitor vital signs
- supine position
- establish an open airway, administer oxygen
- inject 0.3-0.5mL 1:1000 epi IM
- IV diphenhydramine 50-100mg
- CPR if needed
84
Dental management of SLE patients
Pts who are taking Corticosteroids may develop adrenal suppression and could require supplementation, esp for surgical procedures or in case of extreme anxiety.
85
Antiplatelet therapy
Aspirin - inhibits the enzyme cyclooxygenase (COX), which reduces production of PG
Clopidogrel (Plavix) - irreversibly binding to platelet receptors, preventing ADP from binding and activating platelets
Plavix inhibits platelet aggregation by inhibiting ADP induced platelet activation
86
How long does Aspirin last its activity?
Upon discontinuation, aspirin's activity lasts for the life of platelet, appox 7~10days.
87
Anticoagulant therapy
Heparin
Warfarin (Coumadin) - vit K antagonist -> increase INR
Dabigatran (DOAC) - direct thrombin inhibitors
88
Warfarin drug interaction
increase the effect of warfarin
AMX, clindamycin, macrolides
metronidazole, tetracycline,
azole antifungal
fish oil/omega3, vit E, cranberry juice, grapefruit juice
89
Warfarin drug interaction
decrease the effect of warfarin
leafy green vegetables (vit K)
90
INR
INR is used to monitor pts on warfarin
INR 2.0~3.5 little risk of sig bleeding
INR>3.5 sig bleeding may occur
91
Dental management in pts taking antithrombotic agents
1. analgesics
2. bleeding
1. avoid aspirin, NSAIDs
Acetaminophen with or without codeine is suggested
2. in pts taking warfarin, excessive bleeding after invasive dental procedures depends on the level of pt's INR.
If INR>3.5, sig bleeding may occur.
If INR 2.0-3.5, little risk of sig bleeding
92
Local measures for postoperative bleeding
tranexamic acid (TXA)
gauze compression
vasoconstrictive agents (ice or black tea bag, which contain tannins)
93
What is Asthma?
episodic attacks of airway hyperresponsiveness
chronic inflammatory airway disease
94
COPD, Asthma drug
Corticosteroids - inhaled
Decadron (dexamethasone)
Beta2-selective agonist inhalers
Ventolin, Proventil (albuterol)
95
Oral complications of Asthma
1. beta2-agonist inhalers reduce salivary flow by 20~35% - associated with increased prevalence of gingivitis and caries in pts with moderate~severe asthma
2. GERD is common in asthma pts
- beta agonist & theophylline exacerbate asthma
- enamel erosion
3. inhalation steroids - candidiasis
96
Dental management for pts with Asthma
1. analgesics
2. antibiotics
3. anesthesia
4. anxiety
1, avoid aspirin, NSAIDs, narcotics (can depress respiration)
2. avoid azithromycin, clarithromycin, erythromycin in pts taking theophylline
3. avoid anesthetic containing epi d/t sulfite preservative
4. provide a stress-free environment through establishment of rapport to reduce risk of anxiety-induced asthma attack.
if sedation is required, use of N2O or small dose of oral diazepam recommended
97
Dental management for pts with Asthma
5. monitor
6. pt instruction
5. monitor oxygen saturation (normal 97-100%)
when drops below 95%, use low flow supplemental O2
6. determine exacerbating factors
remind pt to bring their rescue inhaler to appointment
98
Drug considerations - Asthma
1. Sulfites may cause allergic reactions.
Sulfite preservatives contained in epinephrine are found in LA.
-> LA without vasoconstrictors may be used in at-risk patients.
2. Aspirin/NSAIDs - not advisable
3. Barbiturates/Narcotics - best not used
4. Theophylline x macrolide (erythro, azithro, clarithro)
99
Management of Asthma attack
1. short-acting beta2 agonist inhaler
2. subcutaneous injection of 1:1000 epi 0.3~0.5mL
3. inhalation of epinephrine
4. positive-flow oxygenation
5. monitor vital signs
6. activate EMS
100
Dental management for pts with COPD
1. drug interaction
2. anxiety
3. chair position
1. avoid ACE in pts taking theophylline
2. avoid N2O (severe COPD pts)
consider low-dose oral diazepam
3. semisupine or upright chair position may be better
101
What issues can occur when liver function is impaired?
1. bleeding tendency
2. altered drug metabolism
3. portal hypertension
4. liver cirrhosis
102
HBV, HCV transmission & postexposure protocols for health care workers
1. Risk of HBV transmission after sharp injury: 6~30%
2. Seroconversion rate for accidental blood exposure to HCV: 2~8%
-> HCV is less infectious and less efficient in transmission than HBV
103
Dental drugs metabolized by Liver
1. LA - lidocaine, mepivacaine, bupivacaine -> safe, higher doses
2. Analgesics - aspirin, ibuprofen, APAP, codeine -> avoid or use reduced doses
3. Sedatives - diazepam -> avoid
4. ABX - metronidazole, vancomycin -> avoid
-> dose may need to be adjusted (half the regular adult dose may be appropriate if cirrhosis or alcoholic hepatitis is present)
104
Dental management of pts with liver disease
1. analgesics
2. ABX
3. anesthesia
1. avoid or limit aspirin, NSAIDs, acetaminophen (not exceeding 2g total dose/day - safe), codeine
avoid benzodiazepine (diazepam)
2. prophylactic abx is not recommended; severe liver dis pts may be susceptible to infection
avoid metronidazole, vancomycin
3. higher doses may be required to achieve adequate anesthesia in alcoholic liver disease pts
Limit 1:100K epi 2 carpules, if portal HTN is present
105
Dental management of pts with liver disease
4. bleeding
5. BP
4. Excessive bleeding may occur in end-stage liver dis pts
pts may need vit K or platelet or clotting factor replacement
5. monitor BP
BP may be increased with portal hypertension
106
Drug considerations for liver disease pts
1. unpredictable drug metabolism
1) in mild to moderate alcoholic liver disease
sig enzyme induction -> increased tolerance of LA, sedative and hypnotic drugs -> larger-than-normal doses may be required to obtain the desired effect
2) more advanced liver destruction
drug metabolism may be diminished -> may lead to an increased effect
2. liver cirrhosis pts should never take acetaminophen - common misconception
1) if taken in appropriate dose (not exceed 2g total dose per day), APAP is one of the safest analgesics for cirrhosis pts.
2) APAP overdose is unintentional. Pts should be educated about over-the-counter and prescription medications that may also contain APAP.
3. NSAIDs should be avoided in cirrhosis pts.
1) NSAIDs can precipitate acute renal failure, 2) increase the risk for thrombocytopenia, 3) gastrointestinal bleeding.
107
Treatment planning modifications of alcoholic liver disease pts
When dental care is provided, the dentist should be aware of liver enzyme induction and CNS effects of alcohol in pts with alcoholism.
-> Liver disease pts may require increased amounts of LA or additional anxiolytic procedures.
108
Oral complications of alcoholic liver disease
nutritional deficiencies can result in glossitis, loss of tongue papilla, angular cheilitis
candida infection
vit K deficiency, spontaneous gingival bleeding
potal hypertension
109
Acid blocking drugs and MOA
1. H2 blocker (histamine receptor antagonist) - cimetidine, ranitidine
2. proton pump inhibitor (PPI) - omeprazole
110
Dental management of pts with gastrointestinal disease
1. analgesics
2. antibiotics
3. Drug interaction with warfarin
1. avoid aspirin, NSAIDs
use acetaminophen or celecoxib in combination with PPI
2. avoid long-term use of antibiotics to minimize risk of pseudomembranous colitis
3. Concurrent use of acid-blocking drugs/PPIs with warfarin (Coumadin) can enhance blood levels of the anticoagulant
111
Drug considerations for PUD pts
1. avoid Aspirin, NSAIDs - if NSAID used, COX-2 selective inhibitor (celecoxib) + PPI
2. APAP recommended
3. acid blocking drugs (cimetidine) decreased the metabolism of diazepam, lidocaine, TCA -> enhance the duration of action -> dosing of anesthetics, benzodiazepines, antidepressants that are metabolized in liver may require adjustment.
= Lower doses of diazepam, lidocane, or TCA may be required if the pt is taking acid-blocking drugs (cimetidine).
4. PPI may reduce absorption of ABX and antifungals -> antibiotics should be taken 2hr before or after antacids are injested
112
Who are at risk of pseudomembranous colitis?
pts older than 65ys old
recent hospitalization
taking broad-spectrum antibiotics (clindamycin, cephalosporin, ampicilln)
HIV seropositive status associated with immune suppresesion
113
Cause & treatment of pseudomembranous colitis
Cause
overgrowth of Clostridium difficile
systematic ABX - clindamycin, cephalosporin, ampicillin
Sx - symptomatic flares and diarrhea, dehydration, hypotension
Tx
mild dis - cessation of offending antibiotics
mod dis - metronidazole
severe - vancomycin
side effect
fungal growth (candidiasis)
metronidazole can cause peripheral neuropathy, nausea, metallic taste
114
Oral manifestations of IBD
aphthous-like lesions occur in up to 20% of pts with UC
pyostomatitis vegetans may aid in the diagnosis
115
Oral manifestation of Crohn's disease
unique oral manifestation of Crohn's disease occur in approx. 20% of pts.
1. atypical mucosal ulcerations and diffuse swelling of the lips and cheeks
2. oral ulcers appear as linear mucosal ulcers with hyperplastic margins or cobblestone proliferation of mucosa in the buccal vestibule and soft palate
oral lesions become symptomatic when the intestinal disease is exacerbated and resolve when medically controlled
116
IBD - Humira, Remicade, Enbrel MOA
TNF alpha blocker - Humira, Remicade, Enbrel
117
How can chronic kidney disease impact dental care?
1. anemia
2. abnormal bleeding
3. electrolyte and fluid imbalance
4. hypertension
5. drug tolerance
6. mineral bone abnormalities
118
Who are the high-risk group of kidney disease?
patients with diabetes and hypertension
>40% of pts with ESRD have diabetes
25% have concurrent HTN
119
What are nephrotoxic drugs?
aspirin, NSAIDs, acetaminophen in high doses
narcotics - prolonged sedation, respiratory depression
aminoglycoside (gentamycin, streptomycin)
acyclovir
tetracycline (except for doxycycline)
-> analgesic alternatives - tramadol or APAP (short term)
120
Is acetaminophen nephrotoxic?
if so, what is alternative?
APAP is nephrotoxic and may cause renal tubular necrosis at high doses. But it is safer than aspirin when used for a short time because APAP is metabolized in the liver.
Alternative analgesic is tramadol.
121
When are drug frequency and dosage adjustment required?
when GFR drops to 50mL/min,
the drug dosage needs to be reduced and the timing of administration must be prolonged
122
Oral complications in chronic kidney disease
1. salivary flow may be diminished -> xerostomia, parotid gland infection, candidiasis
2. saliva has a higher pH, metallic taste, ammonia-like odor
3. bleeding tendency, petechiae of oral mucosa
Tooth
4. enamel hypoplasia and hypocalcification
5. pulp narrowing or obliteration; however, caries is not a feature due to the buffering capacity of saliva
Jaw
6. osseous changes of jaw
1) loss of lamina dura 2) demineralized bone (ground-glass appearance) 3) mandibular expansion (secondary hyperparathyroidism)
7. metastatic calcifications within soft tissue, vascular calcifications of carotid arteries
123
Dental management of pts with end-stage renal disease
1. anestesia
2. antianxiety drug
3. drugs
1. LA - no dosage adjustment
2. nitrous oxide, diazepam - little modification for use - ok
3.
1) Avoid aspirin, NSAIDs, APAP in high doses, narcotics
2) Avoid aminoglycosides
3) Avoid tetracycline
124
Dental management of pts receiving hemodialysis
1. antibiotics
2. day of appointment
3. devices
4. drugs
5, comorbid conditions
1. consider prophylactic antibiotics if abscess is present
2. avoid dental care on day of hemodialysis; best to treat on day after
3. avoid arm with AV shunt for BP measurement
4. consider corticosteroid supplementation if indicated
5. cardiovascular disease, diabetes
approx. 40% of pts on dialysis have congestive heart failure
125
Dental management of pts with stroke
1. analgesics
2. anesthesia
3. antibiotics
4. bleeding
5. emergency care
1. use Acetaminophen; avoid ASA and NSAIDs
2. limit Epinephrine to 2 carpules
3. avoid Metronidazole and Tetracycline
4. INR level of 3.5 or less doesn't require dose modification; if INR is greater than 3.5, dose modification required with physician
5. short and stress free appointment, good anesthesia achieved using N2O, monitor BP and oxygen saturation
126
ABX drug interaction of Coumarin
Metronidazole and Tetracycline may increase INR by inhibiting metabolism of Coumarin (warfarin)
127
What is Parkinson disease
a progressive neurodegenerative disorder of neuron that produce dopamine (depletion of dopaminergic neurons)
2nd most common after Alzheimer disease
128
Drugs used in management of Parkinson disease
Anticholinergic - dry mouth
Levodopa - orthostatic hypotension
129
Dental management in pts with Parkinson disease
1. anesthesia, anxiety
2. BP
3. chair position
4. drug side effect
5. appointment
1. obtain adequate anesthesia and anxiety reduction technique
to prevent exaggerated involuntary movements
2. monitor BP as dopamine can cause hypotension
3. orthostatic hypotension and rigidity are common
- pt should be assisted to and from the chair
- at the end of the appointment, the chair should be inclined slowly
4. Pts who take anticholinergic, dopamine agonists - drowsiness, dizziness
5. during the time of day at which the medication has maximum effect (2-3h after taking it)
130
What is prevalence of Alzheimer disease?
among persons older than 65yrs of age, about 7%
131
What is the cause of Alzheimer disease and medical management?
loss of cholinergic neurons
cholinesterase inhibitors
132
Drugs used in the management of Alzheimer disease
Donepezil (Aricept)
Mamantine (Namenda)
Galantamine (Razadyne)
133
Dental management in pts with Alzheimer disaese
1. analgesic
2. LA
3. communication
1. avoid NSAIDs in pts using cholinesterase inhibitors due to risk of GI irritation and bleeding
2. LA with epi - no issues
3. postive attitude, short words, eye contact, explain what is going to happen
134
Oral manifestations of Alzheimer pts
hyposalivation - dry mouth, candidiasis, periodontal problem, caries, increased risk for aspiration pneumonia
135
Anticonvulsants used in management of Seizures
Phenytoin (dilantin) - gingival hyperplasia
Carbamazepine (tegretol) - xerostomia, gingival bleeding
Valproic acid (depakene) - excessive bleeding
Gabapentin (neurontin) - dizziness
136
Dental management in pts with Seizure
1. bleeding
2. emergency care
1. bleeding tendency associated with Valproic acid (depakene) or Carbamazepine (tegretol)
2. Be prepared for occurrence of tonic-clonic seizure
- place a ligated mouth prop
- dental chair: supported supine position
During seizure
- clear the area
- turn the pt to the side (to avoid aspiration)
- passive restrain
After seizure
- oxygen 100%
- turn pt to the side to control airway, mouth suction
- examine for traumatic injuries
- discontinue tx
137
Drug interaction of benzodiazepines
opioids, psychotropic agents, cimetidine, erythromycin - potentiate CNS depressant effects of benzodiazepines
opioids - decreased dose in pts taking benzodiazepine
psychotropic agents - benzodiazepine
138
Dental management of pts with psychiatric disorders
1. analgesics
2. anesthesia
1. avoid sedative agents or use in reduced dosage in pts taking antidepressant or antipsychotic drugs
To control post-op pain is extremely important in anxious pts
-> dentists should select the most appropriate drug for pain control.
2. Use of epi should be limited (100K epi 2 carpules) in pts taking antidepressants or antipsychotic drugs because hypertensive reaction (with antidepressants) or hypotensive reaction (with antipsychotics) can occur.
139
Dental management of pts with psychiatric disorders
3. anxiety
4. chair position
3. In pts with anxiety, oral sedation may be provided the night before and just before the dental appt with a fast-acting benzodiazepine.
For more anxious pts, N2O, IM sedation (midazolam), IV sedation (diazepam) can be considered.
Establish effective communication - provide explanations of procedures with short question-and-answer breaks to address pt's concerns.
4. Pts taking TCA or MAO inhibitors may be prone to postural hypotension with sudden changes in chair position. Support pt getting out of the dental chair.
140
Dental management of pts with psychiatric disorders
5. drugs
avoid or use in reduced dosage sadatives, hypnotics, narcotic agents in pts taking antidepressants or antipsychotic drugs.
avoid NSAIDs, tetracycline, metronidazole, diazepam in pts taking lithium.
some psychiatric drugs may cause xerostomia
141
What is a major risk factor of substance use disorder?
- early exposure to the drug (during adolescence)
- opioid prescription written for more than 3 days to an adolescent increases the risk of addiction by at least threefold
142
What is reversal agent of Opioids?
Medications of opioid use disorder
Naloxone - opioid receptor antagonist
methadone, buprenorphine - opioid agonist
143
Sedatives-Hypnotics
drugs
MOA
primary sedatives and hypnotics are benzodiazepine
- diazepam, lorazepam, alprazolam
- increase the effect of inhibitory neurotransmitter GABA -> leads to CNS depression
144
Recommendations for prescribing opioids for acute pain in an outpatient dental setting
- prescribe immediate-release opioids instead of long-acting opioids
- when opioids are started for opioid-naive pts with acute pain, prescribe the lowest dosage
- review the pt's history of controlled substance prescriptions using state PDMP (prescription drug monitoring program)
- should use caution when prescribing opioid pain medication and benzodiazepine concurrently.
145
Tx panning consideration in pts with substance use disorders
1. careful selection of pain or anxiolytic medications. may require a reduction in their usual dosage.
2. problems of major clinical importance in pts with alcoholic liver disease include bleeding tendencies and unpredictable metabolism of certain drugs
146
Dental management considerations in pts with substance use disorders
1. analgesics
1. avoid prescribing opioid analgesics
- clock-regulated use of NSAIDs with acetaminophen is recommended
- check state PDMP fist, then prescribe an adequate-strength medication and only a limited number of doses (3 days maximum) with specific instructions, and no refills
147
Dental management considerations in pts with substance use disorders
2. anesthesia
2. For a person who has a cocaine and methamphetamine use disorder, avoid the use of epi for 24h after the last dose of drug. Some pts may require additional anesthesia d/t rapid drug metabolism
Because epi can potentiate the adverse cardiovascular effects of cocaine and amphetamines
148
Dental management considerations in pts with substance use disorders
2. anxiety
if the pt requires an anxiolytic for tx, contact the pt's physician to discuss options.
consider using a short-acting benzodiazepine and prescribe only enough for one appointment.
also consider intra-operative use of N2O
