Special needs pts (sickles and seizures) part 3 Flashcards
Sickle Cell disease: inheritance? what type of defect? prevalence among blood disorders?
- AR
- A molecular defect: substitution of valine for glutamic acid at 6th amino acid in beta-globin gene: this allows HbS to polymerize when deoxygenated
- It is the most common genetic blood disorder
Sickle Cell Trait
Not a SC disease
1/12 Afr Americans
- Considered benign, patients are healthy
- Protective from malarial infection: RBC’s infected by P falciparum sickle and are destroyed
Sickle Cell anemia: genetics? Prevalence in which populations? how is it dx?
Homozygote HbSS
- Dx by neonatal screening : RBCs exposed to deoxygenating agent, sickling of cells occurs if trait or disease is present, if disease sickling occurs rapidly
- 1/600 African ams; Also hispanic, mediterranean and middle eastern
Sickle cell anemia : RBC survival, other issues?
Chronic anemia : Hbg 6-9 g/dL
- Anemia: due to decreased survival of sickled RBCs (normal 120, SC-12 days)
- Delayed growth/puberty
- Susceptible to sepsis
- Bone pain (RBCs trapped in sinusoids)
- Hand/foot syndrome - when small vessels blocked
- Chest syndrome: severe pain, cough/fever dyspnea, sickled RBC block alveoli circulation
- Abdominal pain (liver, spleen, kidney damage)
- Aplastic crisis
- Thrombotic crisis : microvasculature obstruction/stasis
SCA : morbidity/mortality?
Pneumococcal infections: early tx w/antibiotics decreases incidence (may be on long term antibiotics)
- CNS infarction
- Acute chest syndrome
- splenic sequestration crisis
- Life expectancy : late 40’s
Medical management?
Early dx
- Avoid sickling inducing condition conditions: dehydration, acidosis, cold exposure
- blood transfusions regularly
- hydroxyurea : utilized more in adults
Oral findings: soft tissue, bone, teeth, ceph, occlusion
- pale mucosa,
- enamel hypoplasia, dental/jaw pain, delayed eruption, pulp calcifications, decreased caries when taking antibiotics
- Increased incidence of osteomyelitis
- Lateral skull films: “hair on end” appearnce
- Mandible-decreased trabeculae, thin inferior border, distinct radiopacities
- Class 2 : protrusive maxilla
Dental managment of patients w/sickle cell anemia
ASA III- want to avoid elective surgery
- No contraindications to local anesthesia w/vasoconstrictor
- Nitrous oxide: if used minimum of 50% oxygen to avoid hypoxia
- acetaminophen for pain
Define epilepsy
- Prevalence?
- Cause?
Epilepsy is 3 or more recurrent seizures. It involves spontaneous uncontrollable excessive discharge of cerebral neurons.
- Affects 1% of general population
- w/no identifiable etiology
Seizure classification - percent of each?
Partial (40%) can be simple or complex
- Generalized: convulsive or nonconvulsive (40%)
- unclassified
- status epilepticus: seizure lasting >30 minutes
Describe Simple partial seizure: where? what happens to patient? Exs of?
- Originate from localized area of brain
- Pt remains conscious
- Motor autonomic, sensory or psychic symptoms
ie localized muscle twitching, numbness or tingling, chewing/smacking lips, flashes of light, feeling of dissociation from body - 3rd most common form of seizure (15%)
Partial seizures: complex
where? What happens to patient?
Originate from a localized area of brain
- may be preceded by an aura (strange smell, sense of deja vu)
- 1-2 minute loss of consciousness
- Impairment of consciousness may be only symptom
- Motor/autonomic/sensory/psychic symptoms: localized motor activity, paresthesia, overwhelming sense of fear, visual disturbances, distorted perceptions, confusion continues 1-2 mins postictal
- Most common form of seizure (35%)
Generalized seizures: classifications? involvement?
Involve the entire brain and loss of consciousness
- Classified by presentation:
absence, myoclonic, tonic-clonic, atonic, cloni tonic
Absence seizure:
- type of seizure? what occurs (brain, body, looks like)? how long?
Abence is a generalized seizure
- 10-30 second LOC
- brief eye or muscle fluttering
- sudden stop of activity
- Onsent generally 4-10 per year
- 50% w/this will go on to develop tonic-clonic seizures at puberty
- Often misdx as behavior or learning problem
Tonic-Clonic seizures:
- type of seizure? what occurs (brain, body, looks like)? how long?
Tonic clonic is a generalized seizure
- Aura or prodromal mood change-hours to days before seizure
- LOC leads to falling
- Tonic: 10-20 seconds muscle rigidity, 2-5 minutes clonic contractions of muscles of extremities, head, and trunk
- Urinary/fecal incontinence
- Postictal period 10-30 minutes or more, leads to deep sleep, headache, muscle soreness, mental confusion
- Full recovery - 3 hours
- 2nd most common form of seizure (25%)
Other types of generalized seizures: atonic, clonic, and tonic- describe
- Atonic: brief loss of muscle tone, may/may not LoC, many injuries from falls
- Clonic: Alternating muscle contraction and relaxations
- Tonic: persistent firm/violent muscle contractions
Carbamazepine (Tegretol)
Used to tx: simple partial, complex partial, generalized tonic-clonic
- Common side fx: lethargy, ataxia, vision disturbances
- Side fx: liver dysxn, aplastic anemia, leukopenia
- dental: xerostomia, erythromycin elevates blood levels, drug interactions
Ethosuximide
Generalized absence tx
- lethargy, GI distress, hiccoughs
- Can cause rash, leukopenia
- Dental cautions: potential for drug interactions
Gabapentin
Simple partial/Complex partial
- Can cause dry mouth
Phenytoin (Dilantin)
Generalized tonic-clonic
- Ataxia hirsutism
- Can cause gingival hyperplasia
Valproic Acid (Depakene, depakote)
Generalized, all types; simple partial and complex partial
- may cause anemia, thrombocytopenia, pancreatitis
- Gingival bleeding
Common side fx and dental effects of seizure meds (all together now! )
Common side fx: lethargy, dizzy, ataxia, potential for drug interactions
- Dental effects:
1. Xerostomia (Tegretol, nuerotonin)
2. Gingival bleeding (depakene/depakote)
3. Gingival hyperplasia (dilantin)
Dilantin gingival ovegrowth: pathophysiology? prevalence?
Prevalence: 50% of patients on dliantin
- overgrowth is firboepithelial in nature
- w/inflammation gingiva serves as reservoir for dilantin
- Increase in plaque and inflammation related to increase in dilantin induced gingival overgrowth
(hygiene can help but its not everything)
ADHD: Prefontal brain functions what do they allow us to do as it relates to attn?
-incidence of ADHD in school age children? gender?
Prefrontal:
- Maintain attn
- self regulate impulsivity
- Delay gratification
- -Incidence: 3-5% of school age children
- Most commonly dx behavioral disorder in childhood
- More common in boys
Dx of ADHD: what is required? What is ADHD considered? what is it influenced by?
- Behaviors or inattention, impulsivity, hyperactivity:
1. Occur in more than one setting (home/school)
2. Be more severe than in other children same age
3. Start before age 7, even if recognized later
4. Continue for >6 months
5. Make it difficult to fxn in various settings - *ADHD is NOT considered a developmental disorder
- *ADHD is influenced by child’s social environment and school environment as well as child characteristics
Possible etiology of ADHD? inheritance? physical ‘evidence’? other environmental or history possibilities?
Genetic predisposition likelY: 40% hav ea parent w/ADHD, 35% have a sibling w/ADHD
- Genetic evidence of ADHD : increased rate of large copy number variants (chromosomal deletions and duplicates) in individuals w/ADHD
- Brain size 3 to 4 % smaller in ADHD
- systemic: neurotransmitter deficiencies
- also possibly: environmental toxisn, severe head injury, hx of childhood cancer
Types of ADHD : Inattentive only (formerly ADD), symptoms? gender? tx?
- Not overly active
- withdrawn from peers
- symptoms may go unnoticed - late detection
- this form is most common in girls w/ADHD
- Responds to low dose stimulants
Hyperactive/impulsive?
Child can pay attention, child is hyperactive/impulsive
Combined inattentive/hyperactive/impulsive: %, what occurs
the MOST COMMON form of ADHD
- conduct problems, aggression, usually detected early, linear response to stimulants
What are some important co-existing conditions of ADHD and the % of their occurrence? What behaviors do these patients display?
- Oppositional defiant disorder/conduct disorder (35%): break rules, lose temper easily, defiant w/authority figures, destroy property, common w/combined and hyperactive/impulsive subtypes
- Depression (18%): increased risk for suicide in adolescence, inattentive/combined subtypes
- Anxiety disorders (25%): extreme fears/worry/panic. May display physical symptoms.
- Learning disabilities
Behavioral therapy for ADHD?
- Positive reinforcement
- Time out: remove access to activity due to unwanted behavior
- Response-cost: withdraw rewards due to unwanted behavior
- Token economy: combines reward and consequence
–Additional behavioral strategies: keep childo n a schedule, cut down on overstimulating distractions, provide an organized environment, reward positive behavior, set small attainable goals, limit choices, use calm discipline
ADHD Medications and dental side effects:
- Drugs which interact w/ local anesthetics
- name drugs which cause xerostomia
* *precaution in what situation?
- Adderall (dextro-amphetamine) interacts w/Meperidine (demerol)
- - Amoxetine (strattera) interacts with Levonordefrin - Ritalin (concerta), Dextro-ampethamine (adderall), amoxetine (strattera), clonidine and guanfacine (intuniv) all cause xerostomia. aka all ADHD meds
* SEDATION CAUTION: will end up in a deeper state of sedation than intended**
Methyphenidate Ritalin (Concerta): Mechanism of axn, dental efects, systemic side effects
- Non-ampetamine CNS stimulant
- Xerostomia
- Tachycardia, anorexia, insomnia
- -potentiate tCAs
Dextro-amphetamine (adderall): Mechanism of axn, dental efects, systemic side effects
- Amphetamine CNS stimulant
- Xerostomia, altered taste, BRUXism
- Caution w/Meperidine, hypertension, insomnia, anorexia
Amoxetine (strattera): Mechanism of axn, dental efects, systemic side effects, special precautions
- Selective norepinephrine reuptake inhibitor
- Xerostomia
- Anorexia, fatigue, elevated BP, avoid levonordefrin
* *Caution with vasoconstrictors–add to increased BP caused by straterra
Clonidine Catapres: Mechanism of axn, dental efects, systemic side effects
- Antihypertensive
- Xerostomia, dyspagia, sialadenitis (salivary gland bacterial infection w/hyposalivation)
- Potentiates CNS depressants, cardiac arrhythmias
Guanfacine (Intuniv): Mechanism of axn, dental efects, systemic side effects
Special precautions
- Anti-Hypertensive
- Xerostomia, dysphagia
- Hypotension, bradycardia, constipation, dizziness, syncope
* *hypotension and bradycardia, may slow down even more w/sedation
Which ADHD drugs are classified as anti-hypertensives?
- Which ADHD drug has systemic side effects unlike the rest?
Clonidine Catpres
Guanfacine (intuniv)
- Guanfacine(intuniv) causes hypotension, bradycardia, constipation, dizzyness–generally slowing down while all others are more stimulating tachycardia/nervous/anorexia/high BP
