SDCEP Flashcards
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dental infection
1st instance
local measures
drain infection e.g. XLA, incise and drain, extirpate
1st line antibiotics
Phenoxymethylpenicillin tablets 250mg,
send 40tablets,
2tablets 4xdaily for 5 days
Amoxicillin 500mg
Send: 15 tablets
Label: Take 1 tablet three times daily for five days
1st line antibiotics if allergic to penicillin
Metronidazole 400mg
Send: 15 tablets
Label: Take 1 capsule three times daily for five days.
avoid alcohol, and not if on warfarin
2nd line antibiotics
clindamycin capsules 150mg,
send 20capsules,
1capsule 4xdaily for 5days
Co-amoxicalv
ANUG and pericoronitis assoc with which type bateria
anaerobic
local measures for ANUG
remove supra gingival and sub ging depositis and OHI
may be limited in acute phase due to pain
pericoronitis local measures
irrigation and debridement
drug tx for pericoronitis and ANUG if required
metronidazole tablets 200mg
send - 9 tablets
1 tablet 3xdaily for 3 days
not alcohol and not if on warfarin (amox)
sinusitis
generally self limiting (av duration 2.5weeks)
steam inhalayion
ephdrine nasal drops 0.5%, 1 drop inot each nostril up to 3xdaiy when required (10ml total)
predispositon to pseudomembranous or erythematous candidosis
inhaled corticosteroids,
cytotoxics,
broad spectrum antibacterials,
diabetic pts,
nutrional deficiencies,
reduced immunity (leukaemia, HIV)
local measures for candidosis
rinse with water after use of corticosteroid inhaler
denture hygiene
drug tx for candidosis
7 days
* miconazole oromucosal gel 20mg/g (80g tube), apply pea sized amount after food 4xdaily, use for 7days after leasions heal
* fluconazole capsules, 50mg, 1 capsile daily for 7 days
NOT IF ON WARFARIN OR STATINS
nystatin oral suspension, 100,000units/ml, 1ml after food 4xdaily for 7days - retain near lesion for 5mins before swallowing, cont to use for 48hours after lesion healed
angular cheilitis most likely caused by ….
in denture wearing
candida spp.
angular cheilitis most likely causde by….
in non denture wearing pts
streptococcus spp,
staphylococcus spp.
angular cheilitis tx
miconazole cream 2% (20g tube), apply to angles of mouth 2xdaily and use for 10 days after lesions healed (NOT IF ON WARFARIN OR STATINS)
sodium fusidate ointment 2% (15g tube), apply to angles of mouth 4xdaily
if unresponsive - use in miconazole 2% with hydrocortisone 1% and use for max 7days
1st management primary herpetic gingivostomatitis
due to herpes simplex virus
symptomatic relief - nutrious diet, fluids, analagesia, rest, antimicrobial mouthwash
management of sevre primary herpetic gingivostomatitis or if pt immnocompromised
aciclovir tablets 200mg, 1 tablet 5xdaily for 5days
CHX 0.2%
if on lips aciclovir cream 5%
100mg <1yo
managemetn of herpes zoster (shingles)
aciclovir tablets 800mg (shingles treatment pack - 35 tablets), 1 tablet 5xdaily for 7days
reduce pain, incidence of post-herpetic neuralgia and viral shedding
MRONJ dedinition
exposed bone, or bone that can be probed through an IO or EO fistula in the maxillofacial region that has persisted for more than 8weeks in pt with a history of tx with anti-resorptive or anti-angiogenic drugs, and where there has been no history of radiaiton therapy to the jaw or no obvious metastatic disease to jaw
symptoms MRONJ
- delayed healing following dental XLA or other OS
- pain
- soft tissue infection and swelling
- numbness/paraesthesia or exposed bone
- pain or altered sensation in the absence of exposed bone
- can be asymp
what should aim be re MRONJ
get pt as dentally fit as feasible prior to commencing any anti-resorptive or anti-angiogenic drigs, priorting prevantative care
e.g. bisphosphonates, RANKL inhibitors,
examples of drigs which cause MRONJ
alendronic acid
risedronate sodium
zoledronic acid
ibandronic acid
paidronate disodium
sodium clodronate
densomuab
bevacizumab
suntinib
afilbercept
what to advise pt at risk of MRONK
risk of developing MRONJ but small risk and should continue drug regime whilst dental tx happening, record in notes
higher risk of MRONJ when
pt being tx with anti-resorptive or anti-angiogenic drugs for management of cancer
taking bisphosphonates for more than 5 years
concurrently taking a systemic glucocorticoid e.g. predinisolone
what to do if having to do XLA/OS
explore all possible alternatives e.g. RR in absnece of infection
do not prescribe antiobiotic/antiseptic prophylaxis following XLA or other OS tx specifically to reduce MRONJ risk
perform straighforward procedures in primary care
advise pt to contact practice if that have any pain, tingling, numbness, altered senstation or swelling after XLA
review healing
* if XLA socket not healed after 8 weeks and suspect MRONJ or suspect spontaneous MRONJ, refer to OS/SCD as per local protocols
caries risk assessment
7
- clinical evidence of previous disease
- dietary habits - esp frequency of sugary food and drink consumption
- social Hx - socioeconomic status
- F use
- plaque control
- saliva
- MHx
F conc
standard
<3 1000ppm smear
3-6 >1000ppm pea
7+ 1350-1500ppm pea
guidelines re Infective endocardiditis
SDCEP antibiotic prophylaxis against infective endocarditis 2018 – facilitate NICE CG64 2016
pt at inc risk Infective endocardiditis
- acquired valvular heart disease with stenosis or regurgitation
- hypertrophic cardiomyopathy
- previous infective endocarditis
- strutural congenital heart disease
- valve replacement
special consideration with coadiology consultant regarding AB prophylaxis
- pt with any prosthetic valve
- pt with prev episode of infective endocarditis
- pt with congential heart disease
invasive dental procedures
- placement of matrix bands
- placement of subging rubber dam clamps
- sub-ging restorations inc fixed prosthodontics
- endo tx prior to apical stop established
- preformed metal crowns SSC
- full perio exam - inc pocket chart
- sub-ging PMPR
- incision and drainage of abscess
- XLAs
- OS
non-invasive dental procedures
- infiltrations or blocks
- BPE
- supra-ging PMPR
- supra-ging restorations
- removal of sutures
- radiographs
routine management for infective endocarditis risk
Ensure that the patient and/or their carer or guardian are aware of their risk of infective endocarditis and provide advice about prevention, including:
* Explain that having an invasive dental procedure may increase the chances of bacteria entering the bloodstream, this is the same for other invasive medical procedures and for non-invasive procedures (tattoo, piercing)
* Explain that everyday activities, such as toothbrushing, flossing and chewing can also cause transient bacteraemias and stress the importance of good oral hygiene to reduce the risk from oral bacteria.
Give advice on prevention of infective endocarditis to all increased risk patients including:
* the potential benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended;
* dental procedures are no longer thought to be the main cause of infective endocarditis. unclear whether antibiotic prophylaxis prevents infective endocarditis and therefore it may occur whether or not prophylaxis is given.Antibiotics can cause side effects, such as nausea, diarrhoea and allergic reactions and, in rare cases, anaphylaxis and antibiotic-related colitis. Antibiotic resistance.
the importance of maintaining good oral health to prevent infective endocarditis.
Regular dental check ups, OH, diet advice
symptoms that may indicate infective endocarditis, seek GP advice ASAP e
Record that this discussion has taken place in the patient’s clinical notes.
If, following this discussion, the patient requests antibiotic prophylaxis, consider seeking advice from their cardiology consultant,
NICE CG6412 advises that ‘doctors and dentists should offer the most appropriate treatment options, in consultation with the patient and/or their carer or guardian’ and that the final decision should take account of ‘the values and preferences of patients’.
Ensure that any episodes of dental infection in patients at increased risk of infective endocarditis are investigated and treated promptly to reduce the risk of endocarditis developing
symptoms of IE
seek GP advice ASAP esp if they occur together
- high temp/fever 38oC
- sweats/chills esp at night
- breathlessness
- weight loss
- tiredness/fatigue
- muscle, joint or back pain (unrelated to physical activity)
these could be due to less serious infection but need investigated
special consideration infective endocarditis management
Assess the patient, in consultation with their cardiology consultant, cardiac surgeon or local cardiology centre, to determine whether to consider antibiotic prophylaxis for invasive dental procedures
* If, after this process, it is determined that antibiotic prophylaxis is not required, follow the advice for routine management
Where antibiotic prophylaxis is being considered, ensure that the patient and/or their carer or guardian is aware of the risks and potential benefits to allow them to make an informed decision about whether prophylaxis is right for them.
* Hypersensitivity, anaphylaxis, antibiotic-associated colitis (dairrhoea)
* Take AB prophylaxis 1hour before procedure in dental practice and have to stay there
Provide advice about prevention, including:
* the importance of maintaining good oral health;
* symptoms that may indicate infective endocarditis and when to seek expert advice;
* the risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.
Record that this discussion has taken place in the patient’s clinical notes.
Ensure that any episodes of dental infection in this group of patients are investigated and treated promptly to reduce the risk of endocarditis developing.
possible antiobiotics for prophylaxis
amoxicillin 3g Oral powder Sachet, 60mins before procedure
clindamycine capsules 300mg, 2xcapsules 60mins prior to procedure
amox not if allergy to pencillin and careful of INR
capacity
assessment
understand info relevant to decision
retain info to make decision
use infor to make reasoned decision
act on decision
communicate decision
factors for removal M3M
RCS, SIGN
therapeutic
* infections - pericoronitis, osteomyelitis, osteonecrosis
* caries in M3M or adj teeth
* periapical abscess
* perio disease
* other - cyst, tumour
surgical
* M3M in perimeter of surgical field e.g. #
high risk of dental disease
* signifcant risk to M2M e.g. horizontal or mesially impacted
medical indications
* pt need to be dentally fit
accessibility
* restricted/limited access to care e.g. army
pt age
* complications and recovery time inc with age
active surveillance for M3M
non-operative management for retained M3Ms
prescribed, regularly scheduled follow up visits that inc both clinical and radiograph examinations
what are indications that IAN damage could be highly likely
3
- diversion of IDC
- darkening of root where crossed by canal
- interruption of white lines of canal
rood and shehab 7 signs of IDC interraction with M3M
- darkening of the root
- deflectoin of root
- narrowing of root
- dark and bifid apex of root
- interruption of white line of canal
- diversion of canal
- narrowing of canal
get CBCT
general advice for all pt taking anticoag or antiplatelets and require tx that will likely cause bleeding
- plan tx early in day and week
- provide pre-tx instructions
- tx atruamatically, use appropriate local measures and discharge only when haemostasis achived
- place emphasis on use of measures to avoid complications
- POIG and emergency contact details
when not to interrupt anticoagulant and antiplately therapy
3
- pt with prosthetic metal heart valves or coronary stents
- pt who have had pulmonary embolism or deep vein thrombosis in last 3 months
- pt on anticoagulants for cadioversion
low risk of post op bleeding complications
- simple XLA (1-3 teeth with restricted wound size)
- incision and drainage of IO swelling s
- detailed 6PPC
- sub-ging PMPR
- restorations with sub-ging margins
high risk post op bleeding complications
- complex XLA, adj XLAs that will cause large wound or more than 3 at once
- flap raising procedures
- gingival recontouring
- biopsies
examples of Direct Oral Anticoagulants
apixaban
dabigatran
rivaroxaban
edoxaban
DOAC and low bleeding risk tx
tx without interrupting meds
tx early in day
limit initial tx area and assess bleeding before cont
consider staging tx
consider suture and pack
DOACs and higher risk procedures
- advise pt to miss or delay morning dose before tx
apixaban and dabigatran doses
twice a day
for high risk - miss morning dose but usual evening dose time
rivaroxaban and edoxaban doses
1xdaily morning or night
for high risk tx
* if morning dose either delay 4 hours after haem achieved
* if evening dose just usual
example vit k antagonis
warfarin
acenocoumarol
phenindone
how to manage pt on vit K anatagonist
check INR ideally no more than 24hrs prior to procedure (72hrs if pt stable)
INR<4
tx without interrupting medicaiton
INR >/=4
delay tx or refer if urgent
pt on injectable anticoagulant
dalteparin, enoxaparin, tinzaparin
if prophylactic (low) dose - tx without interrupting
if on tx (higher) dose or uncertain on dose - consult with prescriber
management of antiplatelet drugs
aspirin alone - tx without interrupting
if on clopidogrel, dipyridamole, prasugrel or ticagrel or dual therapy - tx without interrupting but expect prolonged bleeding
what if on anticoag and antiplatelet medication
consult with prescriber to assess likely impact on particular durg combo on pt medical condition and bleeding risk
capacity
5
- to act (decide)
- to make a reasoned decision
- to communicate a decision
- to understand a decision
- to retain the memory of a decision
Presumption of capacity from age 16 unless assessed and proven otherwise (Gillick competent)
Parental responsibility ends at age 16
No other person may lawfully give consent on behalf of a patient who has capacity
* Adults with Incapacity act 2000 – needs official documentation
Certificate of Incapacity (section 47 certificate)
* Welfare POA (until capacity back)
when is consent not required
Emergency clinical setting to save life or prevent deterioration of patient
Treatment must be least restrictive of patient’s choices
Should continue to provide care so long as patient is incapacitated- then explain to them once capacity is regained
defintion of consent
The voluntary and continued permission of an appropriately informed person who has the capacity to consent to the** intervention in question** based on a sufficient knowledge of the purpose, nature, likely effects and risks of that treatment, including the **likelihood of its success and any alternatives **to it. Acquiescence under any unfair or undue pressure or where the person doesn’t know what the intervention entails is not consent
GDC standard 3
valid consent
capacity
informed - risks, benefits, alt
specific to planned tx and in date
lawful consent
voluntary
not coerced
not manipulated
GDC Standards
- INTERESTS- Put patients interests first
- COMMUNICATION- Communicate effectively with patients
- CONSENT- Obtain valid consent
- CONFIDENTIALITY- Maintain and protect patients info
- COMPLAINTS- Have a clear and effective complaints procedure
- TEAMWORK- Work with colleagues in a way that is in patient’s best interests
- CPD- Maintain develop and work within your professional knowledge and skills
- WHISTLEBLOWING- Raise concerns if patients are at risk
- PROFESSIONALISM- Make sure your personal behaviour maintains patient confidence in you and the dental profession
AWI 2000
principles
minimal intervention
encourage residual capacity
pt best interests
involve all relevant peers
take account wishes/past wishes of pt
who can give consent if pt unable
welfare POA
welfare guardian
section 47 certificate issued by doctor or specially trained dentist
consent needs to be
6
informed
valid
voluntary
non-manipulative
non-coerced
pt needs to have capacity
informed consent by
5
knowledge of risks
nature of risks
probabilty of success
alternatives
no pressure
valid consent by
3
recent
specific to tx
appropriate to level of tx need
oral dyseasesthesia
burning sensation affecting oral soft tissues in absence of clinically evident mucosal disease
causes of oral dyseasesthesia
9
- nutrional deficiencies - iron/folate/B12 def
- poorly controlled diabetes
- deture - hypersensitivtiy, inadequate space
- mucosal infection - candidiasis
- xerostomia
- parafunction
- pyschological - anxiety dep
- drugs
- allergy
tx for oral dysaesthesia
reassure pt
correct underlying predisposing factors
if symptoms presist/suspect underlying psyhoclogical element - refer to GMP/oral med
* can prescribe amityrptiline/SSRI
local measures for denture stomatitis
- adjust or make new denture
- keep denture out as much as possible
- brush palate
- clean denture - soak in CHX or NaOCl (acrylic only ) for 15mins 2xdaily
prescriptions for denture stomatitis
fluconazole capusles 50mg
send: 7capsules
Label: 1 capsule daily for 7days
Miconazole oromucosa gel 20mg/g
send: 80g tube
label: apply pea sized amount to fitting surface of denture after eating 4xdaily, cont use for 7days after lesion heal
IF PT ON WARFARIN OR STATIN THEN…
Nystatin 100,000 units/ml
Send: 30ml
Label: 1ml after food 4xdaily for 7days, rinse around mouth and retain newar lesion for 5mins before swallowing, continue for 48hrs after lesions healed
cadidosis
predisposed pts
6
- inhaled corticosteroids
- cytotoxics
- broad spectrum antibacterials
- diabetic pts
- nutritional deficiencies
- reduced immunity
prescriptions for candidosis
fluconazole capusles 50mg
send: 7capsules
Label: 1 capsule daily for 7days
Miconazole oromucosa gel 20mg/g
send: 80g tube
label: apply pea sized amount to fitting surface of denture after eating 4xdaily, cont use for 7days after lesion heal
IF PT ON WARFARIN OR STATIN THEN…
Nystatin 100,000 units/ml
Send: 30ml
Label: 1ml after food 4xdaily for 7days, rinse around mouth and retain newar lesion for 5mins before swallowing, continue for 48hrs after lesions healed
angular cheilitis
prescriptions
miconazole cream 2%
send: 30g tube
Label: apply to angle of mouth 2xdaily, cont for 10days after lesions healed
sodium fusidate ointment 2%
send: 15g tube
label: apply to angle of mouth 4xdaily (not longer than 10 days total)
unresposive then - miconazole 2% and hydrocortisone 1%
cream for wet surface
ointment for dry surface
no dentures= bacterial
dentures = fungal and bacterial
28000ppm F prescription
sodium fluouride toothpaste 0.619%
Send: 75ml tube
label: brush teeth with 1cm 2xdaily, spit don’t rinse, avoid eating/drinking for 30mins
only to be used for person prescribed to
5000ppm F prescription
sodium fluoride toothpaste 1.1%
send: 51g tube
Label:brush teeth with 1cm 2xdaily, spit don’t rinse, avoid eating/drinking for 30mins
only to be used for person prescribed to
fluoride mouthwash
sodium fluoride mouthwash 0.05%
send: 250ml
label: rinse 1xdaily with 10ml for 1 min, spit out
use at diff time form brushing
sinusitis prescription
local measures 1st as usually self limiting - steam inhalation
Antibiotics is persistent symptoms/purlent discharge lasting 7days
pheoxymethylpencillin 250mg tablets
send: 40tablets
label: 2 tablets 4xdaily for 5days
doxycycline capsules 100mg (not if on warfarin or pregnant)
send: 8capsules
label: 2capsules on 1st day, followed by 1 capsule daily (7days total)
herpes simplex
local measures
symptomatic relief - fluid, nutrious diet, bed rest, OHI, analgesia, antibacteiral mouthwash
chlorohexidine mouthwash 0.2%
send: 300ml
label: runse mouth 1min with 10ml 2xdaily
hydrogen peroxide mouthwash 6%
send: 300ml
label: rinse mouth 2min with 15ml diluted in half tumbler with warm water 5xdaily
herpes simplex
if immunocompromised or severe infection
aciclovir tablets 200mg
send:25 tablets
label: 1 tablet 5xdaily for 5days
herpes labalis
presciptions
aciclovir cream 5%
send: 2g
label: apply to lesion every 4hours (5xdaily)
for 5days (up to 10 days total)
best in prodromal stage
varicella zoster (shingles)
prescription
systemic antivirals reduce pain and chance of post-herpectic neuralgia and viral shedding
refer all pts to specialist or GMP
aciclovir tablets 800mg (shingles tx pack)
send: 35 tablets
label: 1 tablet 5xdaily for 7days
paracetamol prescription
paracetamol tablets 500mg
send: 40 tablets
label: 2 tablets 4xdaily for 5days
max 4g daily (8x500mg)
ibruprofen prescription
ibruprofen tablets 400mg
send: 20tablets
label: 1 tablet 4xdaily, after food for 5days
max 2.4g (6tablets)
not if NSAID allergy or on aspirin daily
aspirin prescription
aspirin dispersible tablets 300mg
send: 40tablets
label: 2 tablets 4xdaily for 5days
not post XLA
ac
trigeminal neuralgia management
exclude dental cause
refer to GMP/specialist
positive response to carbamazepine confirms dx
will need FBC and LFTs
diclofenac prescription
diclofenac sodium tablets 50mg
send: 15tablets
label: 1 tablet 3xdaily for 5days
if pt takes daily aspirin
TMD management
conservative
* soft diet
* supportive yawning
* analgisia
* splint
* relaxation
can have muscle relaxant - diazepam
dry mouth
management
local - frequent sips of plain water, sugar free sucky sweets
artificial saliva gel
send: 50g
label: apply to mucosa as required
artifical saliva oral spray
send: 100ml
label: spray as requried
arificial saliva pastilles
send: 50 pastilles
label: 1 pastille sucked as required
local meaures of oral ulceration
salt mouthwash, chlorohexidine mouthwash 0.2%
photos
review in 2 weeks -> presist then refer
local analgesia for oral ulceration
benzydamine mouthwash 0.15%
send 300ml
label: rinse or gargle using 15ml every 1.5hrs
benzydamine oromucosal spray 0.15%
send: 30ml
label: 4 sprays onto affected area every 1.5hrs
lidocaine ointment 5%
send: 15g
label: rub sparingly and gently on affected areas
lidocaine spray: 10%
send: 50ml
label: apply as necessary with cotton bud
topical corticosteroids for oral ulceration
**betametasone soluble tablets 500micrograms
send: 100tablets
label: 1 tablet in 10ml water as mouthwash 4xdaily **
beclometasone pressurised inhalation, CFC free
send: 1 200 dose unit
label: 1-2puffs directed onto ulcers 2xdaily
hydrocortisone oromucosal tablets 2.5mg
send: 20tablets
label: 1 tablet dissolved next to 4xdaily
