SDCEP Guidelines Flashcards
Signs and symptoms of an acute apical abscess
Acute inflammation of the soft tissues surrounding the root apex of a tooth
Often caused by tooth decay = pulp necrosis
Can follow trauma
Pain (usually localised to a single tooth, quick onset, tooth TTP)
Swelling of gingiva, face or neck
Possible tooth mobility
Fever
Lethargy
Loss of appetite for children under 16 yrs old
Management of acute apical abscesses?
Initial Management:
- Determine if airway is compromised (can they swallow saliva and push tongue out of mouth)
- If compromised = A&E
- If not compromised: Recommend optimal analgesia, do not prescribe antibiotics unless signs of spreading infection (facial/neck swelling), systemic infection or immunocompromised and advice the patient to seek urgent dental care
Subsequent care to consider:
- Draining of abscess through affected tooth by irrigating the canal with 1-5.25% sodium hypochlorite or 0.2% chlorhexidine gluconate solution before drying and sealing in non-setting calcium hydroxide using a temp dressing material
- Drainage not usually carried out on a primary tooth
- Fluctuant soft tissue swelling = incisional draining asap
- Prescribe appropriate analgesia (NSAID) if drainage is inadequate
- Relieve occlusion of affected tooth if appropriate
Define pericoronitis
Swelling of the soft tissues surrounding a P/E crown
Signs and symptoms of pericoronitis?
Pain Swelling Discomfort with swallowing Limited mouth opening Unpleasant taste or odour from the affected area Fever Nausea Fatigue
Management of pericoronitis?
Airway compromised - A&E
Not compromised:
- Recommend optimal analgesics
- Antibiotics if signs of spreading infection (limited mouth opening, facial swelling), systemic infection or immunocompromised patient
- Rinse with 0.2% chlorhexidine MW or salty water
- Children: Analgesia, soft tissue brushing and rinsing after food
Subsequent care:
- Irrigate using 0.2% chlorhexidine
- Patient advice to keep area clean
- Extract tooth if repeated episodes
- Extract opposing tooth if trauma to the inflamed operculum if tooth is unlikely to achieve function
What are the main acute periodontal conditions?
Acute necrotising gingivitis
Acute necrotising periodontitis
Periodontal abscess
Perio-endo abscesses
Similarities and differences between ANUG and ANUP?
Both are severe inflammatory conditions of the gingiva caused by fusiform bacteria and spirochetes and are common in immunocompromised patients
Necrotising gingivitis related to lesions limited to the gingival tissue
Necrotising periodontitis involved loss of attachment
What is a periodontal abscess?
Represents an active period of periodontal breakdown which occurs whilst there is marginal closure of the deep periodontal pocket occluding drainage.
Develop in deep periodontal pockets.
Commonly seen in patients with untreated periodontitis or as a recurrent infection during treatment
Signs and symptoms of necrotising periodontal disease?
Pain Swelling Bleeding Halitosis Ulcerated gingival tissue Loss of attachment Malaise Fever
Signs and symptoms of periodontal abscess?
Pain and tenderness of gingival tissue Increased tooth mobility Fever and swollen or enlarged regional lymph nodes Presence of swelling on gingiva Suppuration from the gingiva
Perio-endo abscesses signs and symptoms?
Generalised periodontal disease may be present with localised pain
Swelling with or without suppuration on palpation
Deep pocketing to root apex with BOP
Management of acute periodontal conditions?
Initial:
Airway compromised - A&E
Airway not compromised - optimal analgesia recommendation, antibiotics if indicated
Advise patient to seek urgent dental care
Subsequent care:
- For all consider: Therapy with hygienist, dentist or periodontist
- Scaling teeth sub and supragingival (may require LA)
- Prescribing chemical plaque control (hydrogen peroxide and 0.2% chlorhexidine MW)
Necrotising periodontal disease:
- Plus gingival OHI and smoking cessation advice
- Prescribe metronidazole or amoxicillin if systemic involvement or swelling does not subside following local measures (metronidazole 200mg tds 3 days) OR (amoxicillin 500mg tds 3 days)
Periodontal abscess
- Plus scaling and irrigating periodontal pocket
- Extraction
Perio-endo lesions
- Also consider RCT or re-treatment
Management of dentine hypersensitivity?
Advice: Avoid acidic foods or drinks. Apply desensitising toothpaste and apply small amount to affected area
Eliminate other causes of dental pain (e.g. pulpititis)
Consider topical therapies such as fluoride varnish, dentine bonding agents, prime and bond
Reversible pulpitis features?
Inflamed pulp resulting in an exaggerated response to sensibility testing. Tooth is not TTP.
Sensitivity to sweet and cold.
Reversible pulpitis treatment?
Consider temp dressing
Restoring affected tooth
Irreversible pulpitis features?
Inflamed dental pulp resulting in pain that may be difficult to localise to a single tooth but may last several hours
May be dull and throbbing, may worsen with heat and be alleviated by cold
Spontaneous pain
Keeps patient awake
Irreversible pulpitis treatment?
Pulpotomy for children
Pulpectomy for adults using ledermix (corticosteroid-antibiotic paste)
Extract tooth
Signs and symptoms of alveolar osteitis (dry socket)?
Pain (24hrs-48hrs) after extraction
Unpleasant taste or odour from the area
Swelling occasionally
Management of alveolar osteitis?
Initial management:
Recommend optimal analgesia
Stop smoking and improve OH
Advise to seek urgent dental care
Subsequent care:
- Irrigate with saline
- Apply suitable material to dress the socket e.g. alvogyl
- Antibiotics if indicated
Post extraction haemorrhage management?
Initial management
- Rinse mouth with warm water to remove excess blood
- Advise patient to place a rolled up piece of gauze moistened with saline/water over the socket and to bite on it for 20 mins
- If pt is on anticoagulant medication = send pt for emergency care
- When bleeding stopped: Advise patient to avoid alcohol, smoking, exercise or effort for 24 hrs and to not disturb the blood clot
- If bleeding fails to stop and is persistent = A&E
- If not persistent = dental care
Subsequent care
- If pressure does not work, apply haemostatic dressing to the socket (e.g. oxidised cellulose such as surgicel or haemocollagene sponge)
- Suture wound to achieve good soft tissue closure
- If child consider referring to specialist to investigate underlying pathology
- Antibiotics only if indicated
Oral ulceration management?
Local measures:
- Rinse mouth with a salt solution 1/2 tsp in a glass of warm water
- Sodium chloride MW, Chlorhexidine MW 0.2% rinse for 1 minute with 10ml BD
OR Hydrogen peroxide MW 6%
- Benzydamine MW 0.15% rinse or gargle using 15ml every 1 and a half hrs or oromucosal spray form OR Lidocaine ointment 5%, lidocaine spray 10%
How long has it been present:
3 weeks plus = urgent referral to max fax
If less than 3 weeks:
- For all: Recommend optimal analgesia and prescription of topical analgesics (e.g. benzydamine oromucosal spray)
If recurrent and self limiting advise:
- 0.2% chlorhexidine MW (if over 7 years old) and to seek non urgent dental care.
- Doxycyline dispersible tablets 100mg qds for 3 days (for recurrent aphthous stomatitis)
- For children = optimal analgesia, soft diet and advise ulcers usually resolve within 1-2 weeks.
If receiving drug tx or has an underlying medical condition that may be the cause advise them to seek urgent medical care
If ulceration due to ill fitting denture = 0.2% chlorhexidine MW, keep dentures out where possible and seek non-urgent dental care
If trauma from tooth/ortho appliance = non-urgent dental care
If trauma when anaesthetised = avoid smoking, hot liquids and biting cheek and lip
Single ulcer with no trauma - 0.2% chlorhexidine MW until symptoms resolve or if fails to heal in a week see dentist
Subsequent care:
- Fix ill fitting denture
- Prescribe topical steroids:
Betamethasone soluble tablets 500 micrograms - qds dissolved in 10ml water as a MW
Hydrocortisone oromucosal tablets 2.5mg 1 dissolved next to lesion qds
- Referral to dermatology or oral medicine if vesicuobullous disorder suspected
- Primary herpetic gingivostomatitis or herpes zoster infection - if severe symptoms and patient is immunocompromised consider aciclovir, peniciclovir Rx)
- Refer to GMP if drug is causing ulceration
Medical conditions that can cause oral ulceration?
Viral infections:
- Herpetic stomatitis
- Hand, foot and mouth disease
- HIV
- Chicken pox
- Herpangina (CVA4)
Bacterial infections:
- Syphilis
- Tuberculosis
Mucocutaneous disease
- Lichen planus
- Behcet’s syndrome
- Pemphigus vulgaris
- Erythema mutliforme
- Pemphigoid
- Chronic ulcerative stomatitis
Haematological diseases
- Anaemia
- Leukaemia
- Haematinic deficiencies
- Neutropenia
Gastrointestinal disease
- Coeliac disease
- Ulcerative colitis
- Crohn’s disease
Management of ill-fitting or loose dentures?
May cause pain, difficulty speaking and eating
Post stroke paralysis or malignancy can cause ill fitting dentures
Are there signs of stroke? - Emergency care needed
No signs of stroke:
- Optimal analgesia
- Remove dentures
- Non-urgent dental care
- Temporary relining of dentures
- Make new dentures
- Refer to maxfax if malignancy potential
Orthodontic appliance problems?
If inhaled or ingested - emergency care required
For fixed appliances:
- Remove loose components
- Malleable warm onto sharp, removable parts of the appliance causing trauma
- Advise non-urgent orthodontic care
What is sinusitis?
Inflammation of the sinuses with inflammation of the adjacent mucosa.
Most common trigger = viral upper respiratory tract infection
Rarely bacterial in aetiology
Generally self limiting that has an average of 2 1/2 weeks
Pain (headache, facial, upper tooth ache) Nasal congestion/obstruction Decreased sense of smell Fatigue Fever Purulent discharge
Treatment of sinusitis?
Recommend optimal analgesia
Signs of bac infection?
- No signs = Advise steam inhlation and to see GMP
- Bacterial infection (persistent symptoms or purulent discharge for 7 plus days):
Drug treatment - Ephedrine nasal drops 0.5%
Antibiotics - amoxicillin 500mg tds 7 days, OR doxycyline capsules 100mg 2 capsules 1st day, 1 capsule daily
Signs and symptoms of acute tempormandibular joint disorders?
Pain Swelling Joint noises Limited mouth opening Headaches Ear aches Tinnitus
For dislocated jaw - unable to move jaw or jaw is displaced in an open position
TMD management?
Advise NSAIDs/analgesics
Consider short term course of diazepam to relax muscles (addictive)
Advise local heat packs or ice packs
Soft diet, avoid chewing gum and rest
Consider making occlusal splint
Monitor symptoms in follow up
Consider referral to specialist if symptoms do not improve
What is Bell’s palsy?
Acute onset paralysis or weakness of muscles only in the face, usually on 1 side
Bell’s palsy management?
Determine if signs of stroke e.g. facial weakness or distortion, arm weakness, speech problems - emergency care if so
No signs of stroke:
- Protect eyes with a patch, eye lubricants and possibly tape eyelids closed at night
- Advise urgent medical care
- GMP referral
Management of salivary gland obstruction or infection?
Infection:
- Acute gland pain that does not fluctuate with meal times
- Erythema, systemically unwell, parotid swelling, fever
= Seek urgent medical care
Mumps
- Young patient (under 21) experiencing swelling at side of the face under the ear, systemically unwell and raised temperature
- Recommend optimal analgesia, stay at home to avoid spread, urgent medical care
Obstruction without infection (major salivary gland)
- Intermittent pain and swelling, within an hour of meal times, no erythema or fever
- Analgesics, drink fluids, dental care
Obstruction without infection (minor salivary gland)
- (Mucocele) - dental care
Subsequent care:
- Refer to oral and maxillofacial surgery if symptoms persist
- Consider referral for further investigations to identify underlying cause of xerostomia
What patients are predisposed to candidal infections?
Drugs - inhaled corticosteroids, cytotoxics, broad spectrum antibacterials
Patients with diabetes
Nutritional deficiencies
Systemic disease - leukaemia, malignancies, HIV infection (immunocompromised patients)
Prostheses - no exfoliation
Low saliva - no flow = reduces soluble defence
Management of pseudomembranous candidosis and erythematous candidosis?
Own notes:
Idenfify and remove predisposing factors after confirming diagnosis by swab/oral rinse
Guidelines:
If using corticosteroid inhaler - rinse mouth with water or brush teeth after using it
Nystatin suspension poorly tolerated due to taste
Fluconazole/muconazole prescription: Do NOT use if taking warfarin or statins:
- Fluconazole capsules 50mg OD (max of 14 days)
- Miconazole oromucosal gel 80g tube - apply pea sized amount after food 4x daily (do not use for 7 days after lesions have healed)
- If above contraindicated: nystatin oral suspension 100,000 units/ml, 1ml after food qds for 7 days (rinse and then retain suspension near lesion for 5 mins before swallowing, continue to use for 48 hours after lesions have healed)
Monitor symptoms at follow ups
GMP referral if systemically unwell plus candidal infection
What are the 4 main types of angioedema?
Allergic
Idiopathic
Drug induced
Hereditary
Angioedema signs and symptoms?
Sudden onset swelling
Swelling usually around eyes and lips but can affect throat, hands, feet
If difficulties breathing (wheezing), itching (urticaria) and the patient is hypotensive (flushed or faint) = could be anaphylaxis
What is temporal arteritis/giant cell arteritis?
Inflammation and damage to blood vessels in the head, typically the superficial temporal arteries in patients over 50 years old
Signs and symptoms of temporal arteritis?
Pain (headache, unilateral) Burning sensation Swelling Fever Tender to touch Vessels visible and palpable Fatigue Vision difficulties = emergency care required
What medications can cause gingival overgrowth?
Phenytoin
Ciclosporin
Nifedipine
Procyclidine
What medications can cause oral ulceration?
NSAIDs Nicorandil Beta blockers Methotrexate Cytotoxic drugs Sulphonamides Anticonvulsants (phenytoin, carbamazepine) Allopurinol Penicillin Gold
What can cause dry mouth?
Analgesics (opiods) Antidepressants (tricylic) - Amitriptyline SSRI - fluoxetine, citalopram Anticonvulsants - Carbamazepine Beta blockers - Atenolol Diuretics
How to assess the bleeding risk?
Assess whether treatment is likely to cause bleeding and if it has a risk of bleeding complications:
- High risk = complex extractions or more than 3 at once, flap raised, gingival recontouring and biopsies
- Low risk = Simple extractions, drainage of intraoral swellings, 6 ppc, RSD, subgingival margins of restorations
Ask patient about use of anticoagulants or antiplatelet drugs
- If short therm medication (e.g. for acute deep vein thrombosis/pulmonary embolism) consider delaying procedures which may cause bleeding
Ask patient about medical conditions they have
Ask about the patient’s bleeding history
General advice for treating patients on anticoagulants/antiplatelets
Consider consulting their GMP/consultant
If on time limited course of medication delay non-urgent procedures where possible
Tx early in day and week
Atraumatic technique
Local measures
Discharge patient when haemostasis is achieved
Advise paracetamol
Written and verbal POI and emergency contact details
List antiplatelet drugs
Aspirin Clopidogrel Dipyridamole Prasugrel Ticagrelor
What patients may be taking anticoagulants/antiplatelet medications?
Atherosclerosis
Cardiac arryhtmias
After a stroke
After heart valve replacements, cardiac stents and joint replacements
What medical conditions are associated with increased bleeding risk?
Chronic renal failure - associated with platelet dysfunction
Liver disease (caused by alcohol, chronic viral hepatitis, autoimmune hepatitis, primary biliary cirrhosis)
- Reduced production of coagulation factors
- Reduction in platelet number and function due to splenomegaly
- Alcohol excess = bone marrow toxicity and reduced platelet numbers
Haematological malignancy (leukaemiac, lymphomas, myeloma) or myelodsplastic disorder - Impaired coagulation or platelet function
Recent/current chemotherapy:
- Pancytopenia (low RBCs, WBCs and platelets)
Advanced heart failure
- Resulting liver failure
Mild forms of inherited bleeding disorders (haemophilia and von willebrand’s disease)
- Defective or reduced levels of coagulation factors
Idiopathic thrombocytonia purpura
- Reduced platelet numbers
Drugs associated with increased bleeding risk?
Anticoagulants/antiplatelets
Cytotoxic drugs (infliximab, methotrexate, azathioprine) - Can reduce platelet numbers and impair liver function affecting the production of coagulation factors
NSAIDs
- Impair platelet function
Drugs affecting the nervous system:
- SSRIs can impair platelet aggregation
- Carbamazepine - can affect both liver function and bone marrow production of platelets
What is INR?
International Normalised Ratio
- Measures the time taken for a clot to form in a blood sample, relative to a standard
- INR value of 1 indicated a level of coagulation equivalent to that of an average person not taking warfarin
- INR greater than 1 indicates a longer clotting time and longer bleeding time
Used for warfarin, acenocoumarol, phenindione
Amoxicillin can affect the INR level so should be checked 24 hours after starting the antibiotic
How to treat patients taking warfarin/vitamin K antagonists?
For dental treatment likely to cause bleeding:
- Check INR within 72 hours of the procedure, ideally within 24 hrs
- If INR of 4 or above = inform GMP and delay treatment
- If below 4, treat with local measures without interrupting their anticoagulant
- Consider limiting initial treatment area (single extraction, subgingival scaling of 3 teeth) and then assess before continuing
- Carry out treatment in a staged manner over several visits
- Local haemostatic measures: Suturing and packing
- Tx early in week and in the day
- Atraumatic procedure
- Avoid NSAIDs
- Written POIG and emergency details
What are the most common antiplatelet combinations?
Aspirin with clopidogrel (for acute coronary syndrome)
Dipyridamole with aspirin after stroke or TIA (transient ischaemic attack)
Patients with a coronary stent will be prescribed dual antiplatelet therapy for up to 12 months
Dual antiplatelet therapy = increased risk of bleeding than single therapy
How to manage patient’s taking antiplatelet drugs?
Consider limiting initial treatment area (single extraction, subgingival scaling of 3 teeth) and then assess before continuing
- Carry out treatment in a staged manner over several visits
- Local haemostatic measures: Suturing and packing
- Tx early in week and in the day
- Atraumatic procedure
- Avoid NSAIDs
- Written POIG and emergency details
If taking aspirin alone:
- Consider limiting initial treatment area (subgingival scale 3 teeth, single extraction) and assess bleeding before continuing
- Consider staging the treatment
- Local haemostatic measures
Another single antiplatelet drug or dual antiplatelet drugs:
- Be aware that bleeding may be prolonged up to an hour
- Limit initial treatment area
- Stage treatment
- Local haemostatic measures (suture and packing)
- Consider consulting with consultant/GP
List the novel oral anticoagulants and what they inhibit?
Dabigatran - thrombin
Rivaroxaban, apixaban, edoxaban - factor Xa
Dabigatran and apixaban taken x2 daily
Rivaroxaban x1 daily
What tests can be used to assess the levels of coagulation when taking NOAC?
Dabigatran - activated partial thromboplastin time
Rivaroxaban - prothrombin time
Not carried out routinely
How to manage patient’s taking NOACs?
- Limit initial treatment area
- Stage treatment
- Local haemostatic measures (suture and packing)
- Consider consulting with consultant/GP
- Tx early in week and in the day
- Atraumatic procedure
- Avoid NSAIDs
- Written POIG and emergency details
If likely to cause bleeding:
- Miss morning dose of apixaban/dabigatran and delay rivaroxaban
- Take medications again at least 4 hours after haemostasis achieved
- If patient usually takes rivaroxaban in the evening = do NOT modify their medication BUT ensure it is taken 4 hours after haemostasis is achieved
List the injectable anticoagulants and how to manage these patients?
Low molecular weight heparins
Dalteparin
Enoxaparin
Tinzaparin
By subcutaneous injection
May be for pregnant women, venous thrombosis patients with a history of cancer
Consult with GMP/specialist
List the anticoagulant drugs
Oral anticoagulants
- Warfarin
- Phenindione
- Acenocoumarol
Injectable anticoagulants
- Delteparin
- Enoxaparin
- Tinzaparin
What medical conditions may lead to patients having anticoagulant or antiplatelet therapy?
Stoke or ITA - single/dual antiplatelets
Stroke prevention in patients with AF - warfarin or NOAC
DVT/PE - warfarin, NOAC, injectable anticoagulant
Recent surgery - injectable anticoagulatn or NOAC
Heart surgery (especially replacement heart valve) - Warfarin or single platelet therapy
Coronary heart disease (stable/unstable angina, STEMI/non-STEMI) - Single/dual antiplatelet, warfarin, warfarin with single antiplatelet or injectable anticoagulatn
Coronary stent - single/dual
Kidney dialysis - Heparin or injectable anticoagulatn
Pregnancy with associated risk factors for venous thromboembolism - aspirin or injectable anticoagulant
Treatment of DVT in pregnancy - Injectable anticoag
Peripheral vascular disease/peripheral arterial disease - single/dual antiplatelets
Thrombus - warfarin
What does warfarin interact with?
Penicillins (including co-amoxiclav) Metronidazole, erythromycin, clarithromycin NSAIDs Carbamazepine Miconazole, fluconazole
What does aspirin and prasugrel interact with?
NSAIDs
What does clopidogrel interact with?
NSAIDs Erythromycin Carbamazepine Fluconazole Omeprazole
What does dipyridamole interact with?
Aspirin
What do NOACs interact with?
NSAIDs
Carbamazepine
How do vitamin K antagonists work?
Inhibit the vitamin K dependent modification of prothrombin and coagulation factors which are required for haemostasis
What drugs are associated with MRONJ?
Bisphosphonates
- Alendronic acid
- Risedronate sodium
- Zoledronic acid
- Ibandronic acid
- Pamidronate disodium
- Sodium clodronate
RANKL inhibitor
- Denosumab
Anti-angiogenic (treat cancer)
- Bevacizumab
- Sunitinib
- Aflibercept
Define MRONJ
Exposed bone in the maxillofacial region that has persisted for more than 8 weeks in patients with a history of treatment with anti-resoprtive or anti-angiogenic drugs and where there has been no history or radiation therapy to the jaw or no obvious metastatic disease to the jaws
Signs and symptoms of MRONJ?
Delayed healing following a dental extraction or oral surgery
Pain
Soft tissue infection and swelling
Numbness
Paraesthesia
Exposed bone
Pain/altered sensation with no exposed bone
Aetiology of MRONJ?
Suppression of bone turnover
Inhibition of angiogenesis (angiogenesis = formation of new BVs)
Toxic effects on soft tissues, inflammation or infection
How do anti-resoptive drugs work?
Inhibit osteoclast function = decreased bone resorption and remodelling
Jaw has increased remodelling rate compared to other skeletal sites
When are bisphosphonates taken?
Used to reduce the symptoms and complications of metastatic bone disease (particularly breast/prostate cancer and multiple myeloma) Osteoporosis Paget's disease Osteogenesis imperfecta Fibrous dysplasia
What is denosumab and how does it work?
Monoclonal antibody which inhibits Oc function and associated bone resorption by binding to RANK-Ligand
Used to treat osteoporosis and to reduce the skeletal related events related to metastasis
Subcutaneously given every 6 months in osteoporosis
Stays in bone for 9 months post treatment
How do anti-angiogenic drugs work and what are they?
Target the processes by which new BVs are formed and are used in cancer treatment to restrict tumour vascularisation
When does the risk of MRONJ increase?
When bisphosphonates have been taken for over 5 years
Bisphosphonates or denosumab taking systemic glucocorticoids (beclomethasone, betamethasone, cortisone, dexamethasone, hydrocortisone, prednisolone)
Anti-resoprtive or anti-angiogenic drugs for cancer management
Patients with a previous diagnosis of MRONJ
How to manage patients at risk of MRONJ?
Before staring anti-resorptive or anti-angiogenic drug therapy:
- Dental assessment to have dental treatment and do prevention (OHI, duraphat if high caries risk), smoking and alcohol cessation, regular check ups)
- Extract teeth of poor prognosis
- Radiographs
Low risk patients:
- Straightforward extractions and bone impacting treatments can be done in primary care
- Consider less invasive treatment options before extractions
- Inform patient of risks and consequences: Pain, tingling, numbness, swelling, altered sensation
- Review socket healing
- If MRONJ expected = referral to oral surgery
High risk patients:
- Routine dental treatment and prevention
- Consult oral surgery
- If extraction indicated: Discuss risks and benefits, proceed with extraction and review
Key signs and symptoms of anaphylaxis?
Signs
- Marked upper airway oedema and bronchospasm = stridor and wheezing
- Tachycardia (HR >110 per minute) and increased respiratory rate
Symptoms
- Abdominal pain, vomiting, diarrhoea
- Flushing or pallor
Management of anaphylaxis?
Assess patient
Call for ambulance
Secure patient’s airway and help to restore their BP by laying the patient flat and raising their feet
Remove source of anaphylaxis if known, suction if required
Administer 100% oxygen flow rate: 15 litres/minute
Administer adrenaline 0.5ml i.m injection (repeat after 5 mins if needed)
- For 6m-5yr olds 0.15ml
- 6-11yrs 0.3ml
- 12-17yrs 0.5ml
Mild allergic reaction signs?
Urticaria and rash, particularly of chest, hands and feet
Rhinitis, conjunctivitis
Mild bronchospam without evidence of SOB
Management of mild forms of allergy?
Administer 1 cetirizine tablet (10mg) or 1 chlorphenamine tablet 4mg
If patient displays signs of mild bronchospasm:
- Administer a salbutamol inhaler, 4 puffs through a large volume spacer
- Child 12-17 yrs: 1 puff via spacer every 15 secs
Asthma attack signs?
Cyanosis or respiratory rate <8 per minute
Bradycardia (HR <50 per minute)
Exhaustion, confusion, decreased conscious level
Inability to complete sentences in 1 breath
Respiratory rate >25 per minute
Tachycardia (HR >110 per minute)
Management of asthma attacks?
Call ambulance
Assess patient
Sit upright
100% oxygen flow rate 15 litres/minute
Administer the patient’s own bronchodilator (2 puffs) or if unavailable - administer a salbutamol inhaler 4 puffs through a large volume spacer
For children 12-17yrs- 1 puff via a spacer every 15 secs
Signs and symptoms of cardiac emergencies (angina and myocardial infarction)?
Progressive onset of severe crushing pain in the centre and across the chest - pain may radiate down the arms (most commonly left), into neck and jaw or through to back SOB Increased respiratory rate Skin pale and clammy Nausea and vomiting Weak pulse and decreased BP
Management of angina and myocardial infarction?
Assess patient and call ambulance
Administer 100% oxygen flow rate 15 litres/minute
Administer glyceryl trinitrate (GTN) spray sublingually and repeat after 3 mins if pain remains
Administer chewed aspirin 300mg tablet orally (do not use in children due to Reye’s syndrome)
Cardiac arrest key signs?
Loss of consciousness
Absence of normal breathing
Loss of pulse
Dilation of pupils
Cardiac arrest management?
Call for ambulance
Initiate BLS using 100% oxygen or ventilation flow rate 15 litres/minute
Epilepsy key signs and symptoms?
Key signs
- Sudden loss of consciousness, patient may become rigid, fall, cry and become cyanosed (tonic phase)
- Jerking movement of the limbs, tongue may be bitten (clonic phase)
Symptoms
- Brief warning of aura
- Frothing from the mouth and urinary incontenence
Management of epilepsy?
Assess patient
Do not restrain convulsive movements but ensure patient is not at risk from injury - clear the area
Secure patient’s away
Administer 100% O2 15 litres/minute
If fit lasts longer than 5 minutes continue administering oxygen and 10mg midazolam (2ml oromucosal solution, 5mg/ml topically into the buccal cavity)
Fit over:
- Recovery position and check airway
Vasovagal syncope key signs and symptoms?
Patient feels faint, dizzy, light headed
Slow pulse rate
Loss of consciousness
Symptoms:
- Pallor and sweating
- Nausea and vomiting
Vasovagal syncope management?
Assess patient
Lay patient flat and if the patient is not breathless raise their feet
Loosen tight clothing around the neck
Administer 100% oxygen flow rate 15 litres/minute
Hypoglycaemia signs and symptoms?
Aggression and confusion
Sweating
Tachycardia
Shaking and trembling Difficulty in concentration Slurring of speech Headache Fitting Unconsciousness
Management of hypoglycaemia?
Assess pt
Administer 100% O2 15 litres/minute
If pt conscious and cooperative: Administer oral glucose (10-20mg) repeated after 10-15mins
If pt unconscious or uncooperative: Administer glucagon 1mg i.m. injection (children 2-17ys 0.5mg) AND Administer oral glucose 10-20mg when patient regains consciousness
Key signs of stroke?
Facial weakness, one eye may droop or patient may only be able to move 1 side of mouth
Arm weakness
Communication problems - slurred speech, pt cannot understand what is being said to them
Management of stroke?
Ambulance
Assess patient
Administer 100% oxygen 15litres/minute
If unconscious and breathing = secure airway and place in recovery position
Aspiration and choking signs and symptoms?
Patient may cough and splutter
Patient may complain of breathing difficulty
Breathing may become noisy on inspiration (stridor)
Abdominal movements
Cyanosed and loss of consciousness
Aspiration management?
Encourage patient to cough vigorously
Administer 100% oxygen 15 litres/minute
Administer salbutamol inhaler 4 puffs through large volume spacer
Refer patient to hospital for radiograph and removal of fragment inhaled if necessary
Choking management?
Remove foreign bodies from mouth and pharynx Encourage patient to cough Back blows followed by abdominal thrusts If unconscious - BLS Ambulance
Why take care when prescribing antibiotics?
Use of broad spectrum antibiotics is associated with the rise in clostridium difficile associated disease (diarrhoea, fever)
= Take care when prescribing to elderly and those with a history of gastrointestinal disease including the use of proton pump inhibitors for dyspepsia and GORD
Antibiotic resistance
When are antibiotics indicated?
If immediate drainage is not achieved with local measures Spreading infection (swelling, cellulitis, lymph node involvement) Systemic involvement (fever, malaise)
When should the antibiotic dose be doubled?
Severe infections - Extraoral swelling, eye closing or trismus
When should a patient be transferred to hospital as an emergency?
Significant trismus
FOM swelling
Difficulty breathing
Compromised airway if patient cannot swallow saliva or push tongue out of mouth
Management of dental abscesses?
- Airway compromised if patient cannot swallow saliva or push tongue out of mouth
- If compromised = emergency care
- If not compromised: Optimal analgesia and dental care - Pus drainage
- If pus present in dental abscess, drain by extraction of tooth or through root canals by irrigating the canals with sodium hypochlorite solution (1-5.25%) or 0.2% chlorhexidine gluconate solution before drying and sealing with non-setting calcium hydroxide. If endodontic therapy completed, can prescribe NSAIDs for post op pain
- If pus present in soft tissue, attempt to drain by incision. Anaesthetise area using lignocaine with AD injected into overlying mucosa. Horizontal incision parallel to the occlusal surface of the teeth 1-2cm in length. Number 11 blade. Open cavity with artery forceps (Hilton’s method) and hot salt water MW to encourage remaining pus to drain - Antibiotics if immediate drainage is not achieved using local measures or in cases of spreading infection/systemic involvement
- Measure pt’s temp <36 or >38 degrees indicates systemic involvement
- Can treat with amoxicillin, phenoxymethylpenicillin (penicillin V) or metronidazole (effective against anaerobic bacteria and is suitable for those allergic to penicillin)
- Amoxicillin and metronidazole can be used in combination
- Amoxicillin capsules 500mg, tds 5 days
- Phenoxmethylpenicillin tablets 250mg qds 5 days
- Metronidazole tablets 200mg tds 5 days
(Double above doses if signs of severe infection) - If patient does not respond to the antibiotic, check diagnosis and consider referral to specialist before prescribing 2nd line antibiotics (may lead to antibiotic resistance and broad spec. linked to clostridium difficile infec)
- Clindamycin capsules 150g 5 days (effective against penicillin resistant staphylococci)
- Co-amoxiclav 250/125 tablets tds 5 days (active against beta-lactamase producing bacteria that are resistant to amoxicillin)
- Clarithromycin tablets 250mg bd (active against beta lactamase producing bacteria) - Review patients with bacterial infections within 2 to 7 days
- Restore function e.g. trismus (therabite)
What is ANUG?
Painful, superficial infection of the ginigval margins associated with anaerobic fuso-spirochaetal bacteria and is more common in patients who smoke, immunocompromised and poor OH
Management of ANUG?
Local measures:
- Remove supra/subgingival deposits and provide OHI
Systemic involvement/persistent swelling despite local measures:
Metronidazole tablets 200mg tds for 3 days
OR
Amoxicillin capsules 500mg tds for 3 days
What does fluconazole interact with?
Statins
Warfarin
(Also avoid miconazole when taking statins/warfarin)
Denture stomatitis management?
Local measures:
- Brush palate daily
- Clean dentures thoroughly (soak in chlorhexidine MW or sodium hypochlorite for arcylic dentures for 15 mins x2 daily)
- Leave dentures out at night and as often as possible
- If dentures are the problem - adjust or make new ones
Fluconazole 50mg OD 7 days
OR
Muconazole oromcosal gel - pea sized amount to fitting surface of denture after food qds
OR if contraindicated:
Nystatin oral suspension 1ml after food qds for 7 days
Angular cheilitis causes?
In denture wearing patients, usually caused by infection with candida species
Without dentures - streptococcus/staphylococcus (staph aureus) species
Own notes - may be linked to hematological deficiency - iron, B12, folate, crohn’s
Angular cheilitis management?
If dentures are the cause e.g. reduced vertical dimension - adjust or make new ones
Miconazole cream - effective against candida and gram positive species so appropriate unless taking warfarin and statins:
Miconazole cream 2%, apply to angles of mouth bd daily (use 10 days after lesions have healed)
If bacterial in nature:
Sodium fusidate ointment 2%, apply to angles of mouth qds (no longer than 10 days)
If unresponsive
Miconazole 2% and hydrocortisone 1% cream OR ointment
applied to angles of mouth bd (use for maximum of 7 days)
Primary herpetic gingivostomatitis management?
Primary herpetic gingivostomatitis:
- Nutritious soft diet
- Fluids
- Bed rest
- Analgesics
- Antimicrobial MW (chlorhexidine or hydrogen peroxide) to control plaque accumulation if toothbrushing is painful
(chlorhexidine MW 0.2% or hydrogen peroxide MW 6%)
For immunocompromised patients:
Aciclovir tablets 200mg 5 times a day for 5 days
Herpes labialis management?
Aciclovir cream 5% 5x day for 5 days
Apply in prodromal stage of herpes labialis lesion
Herpes zoster infection (shingles) management?
Aciclovir tablets 800mg 5x daily for 7 days to reduce incidence of post-herpetic neuralgia and viral shedding
Own notes (as above plus:)
Analgesics
Opthalmology referral if eye involved
Post herpetic neuralgia treated with neuropathic pain drugs - gabapentin, anti-depressants
Dry mouth management?
Frequent sips of cool drinks, suck on ice or sugar free fruit pastilles or sugar free chewing gum
Consider:
- Artificial saliva gel
- Artificial saliva oral spray
- Sodium fluoride toothpaste 0.619% 2800ppm (if over 10 yrs old)
- Sodium fluoride toothpaste 1.1% 5000ppm if over 16 yrs old
- Sodium fluoride MW 0.05% OD 10ml if over 8 years old
