Lecture 3a: GI disease

Question 1

4 H2 receptor antagonists

Answer 1

Cimetedine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepsid)
Nizatidine (Axid)

Question 2

2 dental management considerations with the use of cimetidine (tagamet)

Answer 2

Delayed liver metabolism of benzodiazepines

Reversible joint symptoms with pre-existing arthritis

Question 3

2 dental management considerations with the use of famotidine (pepsid)

Answer 3

Dry mouth

Anorexia

Question 4

Dental consideration with the use of nizatidine

Answer 4

Potentially increase serum salicylate levels with concurrent aspirin use

Question 5

5 proton pump inhibitors

Answer 5

Omeprazole (rapid release form; Prilosec, zegarid)
Lansoprazole (Prevacid)
Pantoprazole (Protoniz, protium)
Rabeprazole (Aciphex)
Esomeprazole (Nexium)

Question 6

3 drugs whose absorptions may be reduced by proton pump inhibitors

Answer 6

Ampicillin
Ketoconazole
Itraconazole

Question 7

2 PPIs that may increase the concentration of benzodiazepines, warfarin, and phenytoin

Answer 7

Omeprazole

Esomeprazole

Question 8

2 PPIs that may increase the concentration of warfarin

Answer 8

Lansoprazole

Pantoprazole

Question 9

PPI that may increase the concentration of clarithromycin and warfarin

Answer 9

Rabeprazole

Question 10

Prostaglandin drug used for the treatment of peptic ulcer

Answer 10

Misoprostol (Cytotec)

Question 11

2 dental management considerations with the use of prostaglandins for the treatment of peptic ulcer disease

Answer 11

DIarrhea

Cramps

Question 12

3 drugs to avoid prescribing with a history of peptic ulcer

Answer 12

Aspirin
Aspirin-containing compounds
NSAIDs

Question 13

Alternative to aspirin or NSAIDs for analgesic prescription

Answer 13

Acetaminophen and compounded acetaminophen products

Question 14

Analgesic prescription if NSAIDs necessary

Answer 14

COX-2 selective inhibitors in combination with PPI or misoprostol (Cytotec)

Question 15

3 dentally prescribed drugs who have decreased metabolism and enhanced duration of action due to antacids

Answer 15

Diazepam
Lidocaine
TCAs (tricyclic anti-depressants)

Question 16

4 drugs that impair absorption of antacids

Answer 16

Tetracycline
Erythromycin
Oral iron
Fluoride

Question 17

When to give anti-anxiety drugs, antibiotics and dietary supplements with respect to antacid administration

Answer 17

2 hours before or after

Question 18

Risk of H pylori in dental plaque

Answer 18

Reservoir of infection and re-infection along GIT

Question 19

3 points of dental management for a patient with peptic ulcer with risk of H pylori infection

Answer 19

Good oral hygiene
Periodic scaling and prophylaxis
Rigorous hygiene measure should be explained if history of peptic ulcer disease/symptomatic/recurrent

Question 20

Oral complications of using systemic antibiotics

Answer 20

Fungal overgrowth (prescribe antifungal agents)

Question 21

Oral complications for elderly people with peptic ulcer disease

Answer 21

Vascular malformation of the lips

Question 22

When can enamel erosion occur for a patient with peptic ulcer?

Answer 22

Pyloric stenosis –> regurgitation (refer to MD if erosion + hx of reflux)

Question 23

Oral complication of PPIs

Answer 23

Dysgeusia

Question 24

Oral complications of H2 receptor antagonists

Answer 24

Toxic effect of bone marrow

Infrequent anemia, agranulocytosis, thrombocytopenia

Question 25

Oral manifestations of agranulocytosis

Answer 25

Mucosal ulcerations

Question 26

Oral manifestations of anemia

Answer 26

Mucosal pallor | Glossitis (depapillation)

Question 27

Oral manifestations of thrombocytopenia (secondary to hemolytic anemia)

Answer 27

Gingival bleeding or petechiae

Question 28

4 extraintestinal manifestations of ulcerative colitis

Answer 28

* Arhtritis * Erythema nodosum * Pyoderma gangrenosum * Eye --> iritis and uveitis

Question 29

3 extraintestinal manifestations of crohn's disease

Answer 29

Peripheral arthritis Erythema nodosum Aphthous (non-specific ulcer in mouth)

Question 30

IBD profile that suits in-office dental work (4 points)

Answer 30

Mild dz: - No symptoms - No fever - < 4 bowel movements/d w/ little or no blood - ESR < 20 mm/hr

Question 31

IBD profile that requires MD consult (4 points)

Answer 31

Moderate dz or severe - 6+/d w/ blood - Fever - Anemia - ESR >30

Question 32

Anti-inflammatory drugs to be avoided in IBD

Answer 32

Aspirin and NSAIDs

Question 33

2 alternatives to aspirin and NSAIDs for anti-inflammation

Answer 33

Acetaminophen (alone or with opioids) | COX-2 inhibitor + PPI

Question 34

Antibiotic to be cautious with in IBD and why

Answer 34

Clindamycin (can lead to C. diff infection --> diarrhea; very strong and can trigger pseudomembranous colitis)

Question 35

Risk of immunosuppressants in IBD

Answer 35

5% pancytopenia | Increased risk of lymphoma and infection (i.e. mono, recurrent fever)

Question 36

4 points of modification for treatment plan in IBD patient if acute exacerbations

Answer 36

* Determine if anxious / stress / depression * Urgent dental care only * Elective dental care rescheduled during period of remission * Assess current dz severity by taking patient’s temperature and brief ROS (diarrheal bowel movement /d w/ or w/o blood)

Question 37

2 points of management for a IBD patient on sulfasalazine

Answer 37

* Review patient’s systemic health | * Blood test (CBC & diff)

Question 38

2 reasons for taking blood tests for IBD patient on sulfasalazine

Answer 38

* Nephrotoxic --> renal function | * Associated with hematologic abnormalities (leukopenia, thrombocytopenia, anemia..)

Question 39

Profile of patients who are at a higher risk of peptic ulcer disease (4 points)

Answer 39

* >65 years of age * Previous hx of ulcer complications * Prolonged use of NSAIDs * Concomitant use of anticoagulants, corticosteroids and bisphosphonates

Question 40

Profile of patients who are at a higher risk of pseudomembranous colitis (4 points)

Answer 40

* >65 years of age * Hx of recent hospitalization * Taking broad-spectrum antibiotics (clindamycin, cephalosporin, ampicillin) or multiple antibiotics * HIV-seropositive status associated with immune suppression

Question 41

2 risk factors for IBD flare up

Answer 41

* Symptomatic | * Fever

Question 42

Consequential risk of having ulcerative colitis

Answer 42

Colon cancer

Question 43

2 oral complications of ulcerative colitis

Answer 43

Aphthous-like lesions (20%) | Pyostomatitis vegetans

Question 44

6 areas where aphthous-like lesions can occur in UC patients

Answer 44

``` Alveolor Labial Buccal mucosa Soft palate Uvula Retromolar trigone ```

Question 45

4 areas where pyostomatitis can occur in UC

Answer 45

Labial mucosa Gingiva Palate Tongue (rare)

Question 46

2 oral complications of Crohn's disease

Answer 46

* Mucosal ulceration and diffuse swelling of the lip and cheeks (orofacial granulomatosis) * Oral ulcer ~ linear mucosal ulcers w/ hyperplastic margins or papulonodular ‘’cobblestone’’ proliferations of mucosa (buccal vestibule and soft palate)

Question 47

3 medications that are the usual cause of pseudomembranous colitis

Answer 47

* Clindamycin (2 % to 20 %) * Amipicillin or amoxicillin(5 % to 9 % ) * Cephalosporin 3rd generation (<2%)

Question 48

4 medications that are less frequently involved in the development of pseudomembranous colitis

Answer 48

Maclide Penicillins Trimethoprim-sulfamethoxazole (Bactrim, Septra) Tetracycline

Question 49

4 medications that are rare causes of pseudomembranous colitis

Answer 49

Aminoglycosides Antifungal agents Metronidazole Vancomycin

Question 50

Treatment planning modification for patient with pseudomembraous colitis

Answer 50

Delay until resolved

Question 51

Oral complications and maifestations of pseudomembranous colitis

Answer 51

Possible fungal growth in oral cavity