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Medical history Flashcards

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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.
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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

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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.

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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).

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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.

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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.

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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

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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.

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9
Q

Causes of hypertension

A

chronic kidney disease
chronic steroid therapy
hyperthyroidism
sleep apnea

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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

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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)

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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

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13
Q

Losartan, Valsartan

A

Angiotensin II Receptor Blockers
prevent angiotensin II binding

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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

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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

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16
Q

Clonidine (Catapres), Methyldopa (Aldomet), Reserpine

A

alpha2-adrenergic agonists

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17
Q

Hydralazine, Minoxidil (Loniten)

A

direct vasodilators
1. avoid NSAIDs - may reduce antihypertensive effects
2. vasoconstrictor effect - none

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18
Q

HTN - antibiotics

A

Avoid erythromycin, clarithromycin (not azithromycin) with CCBs because the combination can enhance hypotension

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19
Q

HTN-anxiety

A
  1. Use stress reduction protocol
  2. Consider the use of pre-op oral sedation (short-acting benzodiazepine 1hr before procedure)
  3. Consider the use of N2O inhalation sedation intraoperatively (Stanley - 30~50% N2) sedation sig increase in the success of IAN block
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20
Q

HTN-anesthesia

A
  1. Ensure profound LA
  2. 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
  3. Limit to 2 carpules of 1:100K epi (0.04mg)
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21
Q

HTN-BP

A

For pts with starge 2 HTN (BP>140/90), periodic BP monitoring during tx may be advisable.

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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.

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23
Q

orthostatic hypotension

A

postural hypotension - dizzy, faint
BP drops when stranding from sitting or lying down

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24
Q

HTN-chair position

A
  1. Avoid rapid position changes d/t possibility of antihypertensive drug-associated orthostatic hypotension.
  2. After the procedure, allow pt to sit in upright for several mins before dismissing to avoid dizziness.
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25
Q

HTN-drug

A

Avoid long-term (>2wks) use of NSAIDs because these agents may interfere with effectiveness of antihypertensive drugs.

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26
Q

HTN crisis management

A

activate EMS
monitor vital signs
sublingual nitroglycerin
nasal oxygen
aspirin
provide CPR, use AED, if needed

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27
Q

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

A
  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
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28
Q

Etiology of Diabetes Mellitus

A
  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
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29
Q

Types of DM

A

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

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30
Q

Risk factors of DM

A
  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
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31
Q

DM oral complications and manifestations

A
  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
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32
Q

DM-prophy abx

A

prophy abx - not required
poorly controlled DM, FBG>200 + invasive procedure = abx may be given in post-op setting

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33
Q

DM-anesthesia

A

no issues if diabetes is well-controlled
For DM pts with cardiovascular comorbities (HT, recent MI), avoid high amount of epi

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34
Q

DM-anxiety

A

anxiety may impact glycemic control and trigger hypoglycemia

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35
Q

Instruction to DM patients

A

advise to take medications/usual insulin dosage and normal meals on day of dental appointment

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36
Q

DM pts on day of appointment

A
  1. check chairside glycemic values
    use office glucometer to ensure adequate glucose control
  2. have glucose source available if needed
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37
Q

DM-post-op analgesia

A

Aspirin, NSAIDs, tramadol - increase risk for hypoglycemia
* Aspirin, NSAIDs (highly bound to plasma protein, may displace sulfonylureas, glinides)
Opioid - risk for hyperglycemia

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38
Q

When do DM pts undergo dental, surgical procedure?

A

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)

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39
Q

Hypoglycemia - signs and management

A

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

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40
Q

Pts with DM and acute odontogenic infections

A
  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
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41
Q

What are three categories of adrenal insufficiency?

A

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).

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42
Q

Primary adrenal insufficiency - steroid supplementation

A

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

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43
Q

Tertiary adrenal insufficiency - steroid supplementation

A

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.

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44
Q

When do we use synthetic glucocorticoids and how they affect systemically?

A

used in the treatment of autoimmune and inflammatory diseases. they may affect adrenal function
supra-physiologic dosage (10~20mg prednisone), more than 2weeks

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45
Q

Features of Adrenal Crisis
Tx, Risk assessment

A

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

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46
Q

Dental management of pts with possible AI

  1. analgesics
  2. ABX
  3. anesthesia
  4. anxiety
  5. Bleeding, BP
A
  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
  6. BP - continuously monitor BP. If BP drops below 100/60mmHg, consider fluid replacement and supplemental steroid administration.
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47
Q

Dental management of pts with possible AI

  1. capacity to tolerate care
  2. drugs
  3. emergency
  4. follow-up
A
  1. 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.
  2. Drugs - provide steroid supplementation for primary AI during surgery or infection. avoid phenobarbital, phenytoin, ketoconazole at least 24h before surgery
  3. Energency - call 911, apply ice packs, monitor vital signs, start IV saline solution, inject 100 IV of hydrocortisone
  4. F/U - AI pts should be monitored for good fluid balance and adequate BP during the first 24h postsurgery.
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48
Q

What should be considered for pregnant patients?

A
  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
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49
Q

What is the concern in dental treatment for pregnant patient in late 3rd trimester?

A

supine hypotensive syndrome
risk of thromboembolism

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50
Q

Discuss supine hypotensive syndrome

A

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

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51
Q

What is gestational diabetes?

A

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.

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52
Q

Risk factors of gestational diabetes

A

high BP
Cardiovascular dis
family history of type 2 DM
obese BMI>25
polycystic ovary syndrom

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53
Q

What is a common periodontal disease during pregnancy?

A

pregnancy gingivitis
pyogenic granuloma or pregnancy tumor

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54
Q

Cause of pregnancy gingivitis

A

increased secretion of estrogen & progesterone and altered fibrinolysis -> exaggerated inflammatory response to local irritants
prevotella intermedia

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55
Q

Sign and symptoms of pregnancy gingivitis

A

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

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56
Q

Treatment timing during pregnancy

A

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

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57
Q

Analgesics - pregnancy

A

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

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58
Q

Antibiotics - pregnancy

A

FDA classification A or B
AMX, cephalosporin, metronidazole, clindamycin, erythromycin

avoid tetracycline - Tc bind to HA, causing brown discoloration

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59
Q

Anxiety - pregnancy

A

avoid Benzodiazepine
a single, short term use of N2O for less than 30mins is considered safe

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60
Q

Anesthesia - pregnancy

A

Lidocaine, prilocaine with epinephrine - safe during pregnancy

61
Q

N2O guidelines during pregnancy

A
  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
  4. the second and third trimester are safer periods for treatment
62
Q

How can you explain the risk of dental radiography during pregnancy?

A
  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
Q

Reduction of radiation dose to pregnant pts

A

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
Q

Osteoporosis medications and MOA

A
  1. bisphosphonate (Fosamax, alendronate; boniva; zometa, zolendronate)
    - inhibits bone resorption through induction of osteoclast apoptosis
  2. denosumab
    - RANKL inhibitor -> inhibits Oc formation
65
Q

Risk of MRONJ

A

oral bisphosphonate <0.01%
IV bisphosphonate 2~4%

66
Q

Risk assessment of patients who have HIV
How can we gauge disease control and immunosuppression?

A

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
Q

What complications may patients with HIV/AIDS face during dental treatment?

A

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
Q

HIV - analgesics

A

Drug interaction of ARV with below drugs:
Aspirin, NSAIDs
opioid
diazepam
TCA
carbamazepine

69
Q

Medical management of HIV-infected patients

A

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
Q

occupational risk of HIV infection

A

0.3%
PrEP (Preexposure ARV prophylaxis)

71
Q

How can we gauge disease control and immunosuppression?

A

Disease control and immunosuppression may be measured by viral load, CD4 lymphocyte count, CBC

72
Q

Head, neck, and oral lesions and conditions associated with HIV infection and AIDS

A

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
Q

Oral complication that may occur in association with HIV infection

A

Candidiasis (most common), gingival & periodontal disease, NUG, NUP
herpes virus infections, recurrent aphthous ulceration, malignant neoplasm

74
Q

Four categories of hypersensitivity reactions

A

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
Q

Signs and symptoms suggestive of an allergic reaction

A

urticaria, swelling, skin rash, chest tightness, difficulty breathing

76
Q

Adverse reactions of LA

A
  1. allergic reaction - procaine, sulfite in epi
  2. anxiety (syncope)
  3. CNS stimulation -> CNS depression -> toxicity
  4. epinephrine reaction - vasoconstrictor effect
77
Q

penicillin hypersensitivity

A

cephalosporin

78
Q

Aspirin - allergy

A

Aspirin provokes a severe reaction in some pts with asthma

79
Q

NSAIDs contraindication

A

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
Q

Type I hypersensitivity - oral complications and management

A

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
Q

Angioedema management

A

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
Q

Type III hypersensitivity

A

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
Q

Anaphylaxis management

A
  • 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
Q

Dental management of SLE patients

A

Pts who are taking Corticosteroids may develop adrenal suppression and could require supplementation, esp for surgical procedures or in case of extreme anxiety.

85
Q

Antiplatelet therapy

A

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
Q

How long does Aspirin last its activity?

A

Upon discontinuation, aspirin’s activity lasts for the life of platelet, appox 7~10days.

87
Q

Anticoagulant therapy

A

Heparin
Warfarin (Coumadin) - vit K antagonist -> increase INR
Dabigatran (DOAC) - direct thrombin inhibitors

88
Q

Warfarin drug interaction
increase the effect of warfarin

A

AMX, clindamycin, macrolides
metronidazole, tetracycline,
azole antifungal
fish oil/omega3, vit E, cranberry juice, grapefruit juice

89
Q

Warfarin drug interaction
decrease the effect of warfarin

A

leafy green vegetables (vit K)

90
Q

INR

A

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
Q

Dental management in pts taking antithrombotic agents

  1. analgesics
  2. bleeding
A
  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
Q

Local measures for postoperative bleeding

A

tranexamic acid (TXA)
gauze compression
vasoconstrictive agents (ice or black tea bag, which contain tannins)

93
Q

What is Asthma?

A

episodic attacks of airway hyperresponsiveness
chronic inflammatory airway disease

94
Q

COPD, Asthma drug

A

Corticosteroids - inhaled
Decadron (dexamethasone)

Beta2-selective agonist inhalers
Ventolin, Proventil (albuterol)

95
Q

Oral complications of Asthma

A
  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
Q

Dental management for pts with Asthma

  1. analgesics
  2. antibiotics
  3. anesthesia
  4. anxiety
A

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
Q

Dental management for pts with Asthma

  1. monitor
  2. pt instruction
A
  1. monitor oxygen saturation (normal 97-100%)
    when drops below 95%, use low flow supplemental O2
  2. determine exacerbating factors
    remind pt to bring their rescue inhaler to appointment
98
Q

Drug considerations - Asthma

A
  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
Q

Management of Asthma attack

A
  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
Q

Dental management for pts with COPD

  1. drug interaction
  2. anxiety
  3. chair position
A
  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
Q

What issues can occur when liver function is impaired?

A
  1. bleeding tendency
  2. altered drug metabolism
  3. portal hypertension
  4. liver cirrhosis
102
Q

HBV, HCV transmission & postexposure protocols for health care workers

A
  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
Q

Dental drugs metabolized by Liver

A
  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
Q

Dental management of pts with liver disease

  1. analgesics
  2. ABX
  3. anesthesia
A
  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
Q

Dental management of pts with liver disease

  1. bleeding
  2. BP
A
  1. Excessive bleeding may occur in end-stage liver dis pts
    pts may need vit K or platelet or clotting factor replacement
  2. monitor BP
    BP may be increased with portal hypertension
106
Q

Drug considerations for liver disease pts

A
  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
Q

Treatment planning modifications of alcoholic liver disease pts

A

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
Q

Oral complications of alcoholic liver disease

A

nutritional deficiencies can result in glossitis, loss of tongue papilla, angular cheilitis
candida infection
vit K deficiency, spontaneous gingival bleeding
potal hypertension

109
Q

Acid blocking drugs and MOA

A
  1. H2 blocker (histamine receptor antagonist) - cimetidine, ranitidine
  2. proton pump inhibitor (PPI) - omeprazole
110
Q

Dental management of pts with gastrointestinal disease

  1. analgesics
  2. antibiotics
  3. Drug interaction with warfarin
A
  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
Q

Drug considerations for PUD pts

A
  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
Q

Who are at risk of pseudomembranous colitis?

A

pts older than 65ys old
recent hospitalization
taking broad-spectrum antibiotics (clindamycin, cephalosporin, ampicilln)
HIV seropositive status associated with immune suppresesion

113
Q

Cause & treatment of pseudomembranous colitis

A

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
Q

Oral manifestations of IBD

A

aphthous-like lesions occur in up to 20% of pts with UC
pyostomatitis vegetans may aid in the diagnosis

115
Q

Oral manifestation of Crohn’s disease

A

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
Q

IBD - Humira, Remicade, Enbrel MOA

A

TNF alpha blocker - Humira, Remicade, Enbrel

117
Q

How can chronic kidney disease impact dental care?

A
  1. anemia
  2. abnormal bleeding
  3. electrolyte and fluid imbalance
  4. hypertension
  5. drug tolerance
  6. mineral bone abnormalities
118
Q

Who are the high-risk group of kidney disease?

A

patients with diabetes and hypertension

> 40% of pts with ESRD have diabetes
25% have concurrent HTN

119
Q

What are nephrotoxic drugs?

A

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
Q

Is acetaminophen nephrotoxic?
if so, what is alternative?

A

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
Q

When are drug frequency and dosage adjustment required?

A

when GFR drops to 50mL/min,
the drug dosage needs to be reduced and the timing of administration must be prolonged

122
Q

Oral complications in chronic kidney disease

A
  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
Q

Dental management of pts with end-stage renal disease

  1. anestesia
  2. antianxiety drug
  3. drugs
A
  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
Q

Dental management of pts receiving hemodialysis
1. antibiotics
2. day of appointment
3. devices
4. drugs
5, comorbid conditions

A
  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
Q

Dental management of pts with stroke
1. analgesics
2. anesthesia
3. antibiotics
4. bleeding
5. emergency care

A
  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
Q

ABX drug interaction of Coumarin

A

Metronidazole and Tetracycline may increase INR by inhibiting metabolism of Coumarin (warfarin)

127
Q

What is Parkinson disease

A

a progressive neurodegenerative disorder of neuron that produce dopamine (depletion of dopaminergic neurons)
2nd most common after Alzheimer disease

128
Q

Drugs used in management of Parkinson disease

A

Anticholinergic - dry mouth
Levodopa - orthostatic hypotension

129
Q

Dental management in pts with Parkinson disease
1. anesthesia, anxiety
2. BP
3. chair position
4. drug side effect
5. appointment

A
  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
Q

What is prevalence of Alzheimer disease?

A

among persons older than 65yrs of age, about 7%

131
Q

What is the cause of Alzheimer disease and medical management?

A

loss of cholinergic neurons
cholinesterase inhibitors

132
Q

Drugs used in the management of Alzheimer disease

A

Donepezil (Aricept)
Mamantine (Namenda)
Galantamine (Razadyne)

133
Q

Dental management in pts with Alzheimer disaese
1. analgesic
2. LA
3. communication

A
  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
Q

Oral manifestations of Alzheimer pts

A

hyposalivation - dry mouth, candidiasis, periodontal problem, caries, increased risk for aspiration pneumonia

135
Q

Anticonvulsants used in management of Seizures

A

Phenytoin (dilantin) - gingival hyperplasia
Carbamazepine (tegretol) - xerostomia, gingival bleeding
Valproic acid (depakene) - excessive bleeding
Gabapentin (neurontin) - dizziness

136
Q

Dental management in pts with Seizure
1. bleeding
2. emergency care

A
  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
Q

Drug interaction of benzodiazepines

A

opioids, psychotropic agents, cimetidine, erythromycin - potentiate CNS depressant effects of benzodiazepines

opioids - decreased dose in pts taking benzodiazepine
psychotropic agents - benzodiazepine

138
Q

Dental management of pts with psychiatric disorders
1. analgesics
2. anesthesia

A
  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
Q

Dental management of pts with psychiatric disorders

  1. anxiety
  2. chair position
A
  1. 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.
  2. 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
Q

Dental management of pts with psychiatric disorders

  1. drugs
A

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
Q

What is a major risk factor of substance use disorder?

A
  • 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
Q

What is reversal agent of Opioids?
Medications of opioid use disorder

A

Naloxone - opioid receptor antagonist
methadone, buprenorphine - opioid agonist

143
Q

Sedatives-Hypnotics
drugs
MOA

A

primary sedatives and hypnotics are benzodiazepine
- diazepam, lorazepam, alprazolam
- increase the effect of inhibitory neurotransmitter GABA -> leads to CNS depression

144
Q

Recommendations for prescribing opioids for acute pain in an outpatient dental setting

A
  • 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
Q

Tx panning consideration in pts with substance use disorders

A
  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
Q

Dental management considerations in pts with substance use disorders

  1. analgesics
A
  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
Q

Dental management considerations in pts with substance use disorders

  1. anesthesia
A
  1. 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
Q

Dental management considerations in pts with substance use disorders

  1. anxiety
A

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

Oral Board - medical history (1 decks)

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