Oral Medicine V - Brennan's Bespoken Bane Flashcards
Dyskinesias affect the jaw
Levodopa
True
What is the ideal pre-Tx drug regimen for Parkinson’s pts?
Take meds 60-90 minutes prior to appt
*peak response period
**also, brief visits
Palpitations:
A-fib
atrial fibrillation
An estimated 2.6 million Americans have A-fib, number is increasing, and is responsible for ______% of all Strokes
15-20%
4 comorbidities to A-fib
Coronary artery disease
CHF
Diabetes
Thyrotoxicosis
3 Therapies for A-fib
Meds (Antithrombotics, combo, alternative)
Cardioversion
Ablation
New Comparative Study, Tx of CVA can be safely administered w/in what time period?
As long as what?
A few weeks of CVA
Kept under optimal medical surveillance
Most common Inherited Clotting Disorder:
Hemophilia A
(1 in 5,000 male births)
Hemophilia B
(1 in 30,000 male births)
Hemophilia A is a Factor ___ deficiency (80%)
Hemophilia B is a Factor _____ deficiency (13%)
6% is a factor ____ deficiency
Factor VIII
Factor IX
Factor XI
Vitamin K rich foods are
Green
If you lack one coagulating factor it is…
If you lack multiple coagulating factors it is….
Inherited disorder
Acquired disorder
4 Vitamin K factors made in the LIVER:
II
VII
IX
X
Factor XII, XI, IX
Factor VII
Intrinsic system/Tissue Factor pathway
Extrinsic system/Contact pathway
3 lab tests for Coagulation Disorders
aPTT - Activated Partial Thromboplastin Time
PT - Prothrombin Time
Platelet Count
aPTT tests the ______ system. What 4 factors?
PT tests the _______ system. What 5 factors?
Platelet Count deals w/ primary _____
Intrinsic VIII, IX, XI, XII
Extrinsic VII, V, X, prothrombin II, fibrinogen I
Hemostasis
Some pts might not be forthcoming about bleeding disorders - what is an important question to ask?
Do you bleed or bruise easily?
5 Uses for Warfarin
*what 2 have higher anticoagulation and higher risk of morbidity
Prosthetic Heart valves
Hx deep venous thrombosis
MI
Stroke
Atrial Fibrillation
What INR and PT levels would you not worry about (discontinuation not necessary for minor OS)
INR < 3.5
PT < 20 seconds
Primary concern for pts on Warfarin:
Physician Consult?
Recourse for excessive bleeding:
Post Op:
Hemostasis
Order/review lab values - perioperative change likely
GelFoam/thrombin, bone wax, Amicar/Tranexamic acid rinses
Acetominophen/codeine
PT < 20 seconds, INR < 3.5
These measurements should be takend w/in _____
You can make changes to anticoagulation therapy
24 hrs
False
3 Issues w/ Warfarin:
Narrow therapeutic window
Frequent monitoring
Food/Drug interactions
What consumables increase the effects of Warfarin?
What decreases?
Wine, cranberries
Green, Vitamin K rich foods
Pain med interactions w/ Warfarin:
Abx interactions:
ASA, NSAIDS, Acetaminophen
Tetracycline, ampicillin, amoxicillin/clavulanic acid (augmentin)
What Abx should you take w/ pt on Warfarin? (2)
Pen V or Clindamycin
T/F
Lit supports altering anticoagulant regimen prior to dental procedures and surgery
False
*go by 3.5 rule
Clinical judgement, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision
Frame and put on wall
3 Antiplatelet agents:
ASA (and NSAIDS)
Ticlid
Plavix
Antiplatelets are used primarily for prophylaxis of:
Secondary prevention of adverse ________
in pts with Hx of _______, _______, and ______
Coronary Thrombosis
Thromboembolic events
Coronary thrombosis, Stroke, Unstable Angina
Do NOT mix up coagulation factors w/ Anti-Platelets - What does INR measure?
Coagulation (warfarin)
NOT platelets (ASA, etc)
Best test for ASA platelet effect is PFA 100 or Ivy bleeding time
Not a problem unless Bleeding time is greater than ______
True
20 minutes
NSAIDS will increase bleeding time how?
Generally you must wait 3 half lives (w/ wide variance between drugs)
Antiplatelet
True
6 ways to increase clinical risk of bleeding through antiplatelet activity:
ASA
NSAIDS
EtOH
Age
Liver disease
existing coagulopathies
Clinical recommendation for pts on Antiplatelet therapies:
Little/No indication to interrupt antiplatelet drugs for dental procedures
It is not necessary to interrupt low dose aspirin therapy for simple dental extractions
True
*really any ASA dose
Drug Eluting Stents (DES) is often clopidogrel, plavix, etc and when combined with ASA…
Decreases cardiac events after stenting
DES, premature discontinuation of antiplatelet therapy greatly increases the risk of what 3 things?
Stent Thrombosis
MI
Death
DES usually has ASA/Plavix dual Tx for how long after Stent placed?
Postpone Elective surgery for how long?
If surgery cannot be deferred, what do?
12 months
12 months
continue ASA perioperatively
3 reasons for Warfarin replacement drugs:
Wide therapeutic index
Few Drug/Food interactions
Predictable anticoagulant response at fixed doses
3 new oral Anticoagulants (Warfarin replacements)
Dabigatran
Rivaroxaban
Apixaban
New oral Anticoagulants (Xarelto, etc) have what major flaw
No reversal agent
What is the reversal agent for Warfarin?
New drugs?
Vitamin K
nothing
If pt taking new Anticoagulants, what 3 lab tests do you need prior to surgery?
aPTT
TT
anti-factor Xa
Warfarin acts on what 4 clotting factors:
Unfractioned Heparin on what 2:
Rivaroxaban (and Apixaban):
Dabigatran:
VIIa, IXa, Xa, Thrombin
Xa, Thrombin
Xa
Thrombin
2 new drugs act on Factor X:
1 new acts on Factor II (Thrombin):
Rivaroxaban, Apixaban
Dabigatran
T/F
It does not appear Dabigatran discontinuation is necessary (if renal function, etc ok)
True
Type 1 diabetics have a deficiency of insulin secondary to destruction of what cells?
Type II is either faulty receptors to insulin or antibodies to those insulin receptors or insulin itself
In either case, what is the result?
Beta cells
True
Hyperglycemic State
Hyperglycemia, short term polyphagia, polyuria, polydipsia, ketoacitosis/hyperosmotic coma
What is the long-term consequence?
Microangiopathy
*and deposition, delayed healing, infection
Diabetes Diagnosis, blood Glucose:
HbA1c must be what in well-controlled diabetics:
> 126 mg/100mL
<7%
Xerostomia, Infection, poor wound healing, increased perio/caries, etc
Diabetes
There is a significant bleeding risk in Diabetes
False
Epinepherine concern in Diabetes:
epi in LA increases blood Glucose
Well-controlled diabetics can tolerate dental care _____
If cardiac complications…
normally
precautions
Diabetes: Morning appts, pts eat normally. Have what to monitor?
What in case of hypoglycemia?
Glucometer
fast-acting carbs
In uncontrolled diabetes, provide what care only?
Emergency
Controlled diabetics Abx
Uncontrolled:
like everybody else
heightened risk for Infection (Use post-op Abx)
Normal thyroid feels…
Enlarged feels…
rubbery
soft
If untreated Hyperthyroidism, avoid…
If untreated Hypothyroidism, avoid…
Epi
CNS depressants
Hydrocortisone (100-300 mg), CPR, IV glucose Tx for crisis in both Hyper and HypoThyroid
True
In well-controlled thyroid disease, Tx infections normally
True
Osteoporosis of alveolar bone, caries, etc
Cretinism, enlarged tongue, etc
Pain to ear, jaw, occiput, dysphagia, enlarged, firm nodular, and tender thyroid
Thyrotoxosis
Hypothyroidism
Thyroiditis
Possible labe tests for organ transplantation Bleeding time:
liver disease:
renal disease:
platelet count, WBC count, hematocrit
AST, ALT, alkaline phosphatase, PT, bilirubin
creatinine, BUN, specific gravity urine, proteins in urine, hematocrit, WBC, pTT
3 important factors in Dentistry to consider in pts w/ transplants:
bleeding
infection
build-up drugs/toxic metabolites (liver/kidney)
Oral signs of Immunosuppression include HSV, apthous, CMV, candidiasis…
Mucositis
Bone Marrow suppression drug that Increases chance for infection:
affects liver/kidney, causes gingival hyperplasia
Azathiprine
Cyclosporine
Avoid dental care Tx for how long after a Transplant?
6 months
Pre-transplant Tx
Med consult
prophy Abx, other mods, labs
4 Drugs to Increase Interval/Change after Organ Transplant
Acetaminophen
Penicillin V
Cephalexin
Tetracycline (or Doxy)
If Abx prophylaxis, give what ideally?
plus…
If allergic?
or Impenem, dosage:
Can’t take orally:
plus…
What shouldn’t be used in Organ Transplant pts b/c of acute Liver Toxicity?
Amoxicillin, 2g orally 1 hr prior
500 mg oral 1 hr prior
Vancomycin, 1g IV infused slowly over 1 hr prior
1g IV infused 1hr infused slowly prior
Apicillin, 2g IV 1 hr prior
metronidazole 500 mg IV 1 hr prior
Clindamycin
Transplant issues, anticoagulation via meds, rejection
Stress - may need steroid supplementation if adrenal suppression
Mucositis, viral infection, aphthous, etc
True
Blood Glc reading = 65
Tx w/ fast acting carbs
Post-op Abx in Diabetes:
only for Uncontrolled
Uncontrolled Diabetic Cardiac Guidelines:
None
*no subset here, follow Cardiac Guidelines
Fasting Glucose threshold for Diabetes:
126 mg/100 mL
If pt on ASA, what lab test prior to Extraction?
None
*nothing for Anti-platelets!!!
Warfarin affects what clotting factors (number and name):
VIIa (tissue factor)
IXa
Xa
IIa (Thrombin)
Extrinsic, Tissue Factor pathway, what Factor?
VII
Med Consult during Chemo?
Postpone when Platelets below…
or Neutrophils below…
Always
50,000
1,000 mm3
Tx of Uncontrolled Diabetics when?
only during Emergency
Parkinson’s, take meds - minuted prior and keep brief
60-90 minutes prior
Old research on stroke, wait….
New research, Tx w/in ____ as long as surveilled
6 months
a few weeks
4 Vitamin K dependent factors:
II, VII, IX, X
*warfarin
Clotting factor II:
IIa:
I:
Ia:
Prothrombin
Thrombin
Fibrinogen
Fibrin
If on Warfarin, INR <
PT <
Should be measured w/in
3.5
20 sec
24 hrs
New drug, Thrombin inhibitor:
3 Factor Xa inhibitors:
Dabigatran (Pradaxa)
Rivaroxaban, Apixaban, Edoxaban
2 Abx ok to use w/ Warfarin:
PenV
Clindamycin
Asthma, instruct pt to bring Inhaler, consider _____ if severe.
Emergency, use…
pulse ox during Tx
Ventolin/Proventil (short acting beta 2 adrenergic)
COPD 4 clinical considerations:
Stability of pt
chair position
avoid Rubber Dam
Low-flow supplemental Oxygen
Almost everyone w/ Asthma has what Drug Allergy?
ASA
Chronic Bronchitis, chronic cough w/ sputum production for what time period?
3 consecutive months
2 successive years
Hypercapnea
too much CO2 (COPD)
Theophylline:
COPD (Stevens-Johnson syndrome)
Unstable COPD pt (below 91% Oxygen) must have what 2 mods?
Upright
Pulse ox
Stable COPD, ok to use diazepam
must be upright
True
True
Early stage tumors:
Advanced stage:
surgery
chemoradiotherapy
Pre-cancer oral health exam should be done when?
1 month prior cancer Tx
Common radiation side-effect
Trismus
*difficulty opening
Radiation Therapy, dental procedures should be done how long prior?
If ortho bands
fabricate…
Endo in field:
Endo out of field:
avoid removables, fabricate dentures _____ post surgery/radiation
10-14 (idally 21) to heal
remove
custom gel-applicator
Extract, no re-treats
RCT can be done
3-4 months
If chemo, ask Oncologist cancer, stage, palliative/curative, prognosis
blood:
clotting factors:
Tx schedule (so safe dental Tx can be delivered)
True
CBC, neutrophil, platelet
if invasive
true
If possible, all dental Tx should be done ___ prior to Chemo
Extractions should be done how long prior ideally?
minimum?
1 week
3 weeks
10-14 days
When do you need a Med Consult if pt on Chemo?
Always
*even prophys
If pt on Chemo, when would you postpone Tx? (2 cases)
platelet count < 50,000
neutrophil count < 1,000
When would you schedule a Chemo pt?
17-20 days post Tx (when they feel best)
Hematopoietic stem cell transplantation:
Intentional destruction of Marrow
stem cell transplant
3 types of Hematopeitic Stem cell transplants
Autologous (own cells)
Allogenic (own species)
Syngeneic (identical twin)
HSCT similar guidelines to Chemo
True
HSCT, delay elective procedures for how long?
Greatest risk of complications:
1 year
100 days
*180 days autologous, 365 allogeneic for standard care
True
Painful, ulcerative oral complication of Radiation
Oral Mucositis
Mucositis, xerostomia, candidiasis, osteoradionecrosis,
Trismus
Radiation
Mucositis, ural ulceration, anemia, thrombocytopenia, infection, neurotoxicity, osteonecrosis of the jaw, xerostomia
Chemotherapy
Anticonvulsants can modify the pathologic process and decrease orofacial pain
True
HSCT prevalence of Oral Complications:
80%
*severe immunosuppression
GVHD manifests orally as atrophy, erythema, white striations, plaques (similar to lichen planus), xerostomia, taste changes, formation of mucoceles, and mucosal sclerosis
True
If neutrophil count is below 50,000, what is needed
Abx prophylaxis
All procedures 1 week prior to chemo
17-20 days post
True
If Controlled Diabetes what might you need to do prior to Tx
current HbA1c
