Dental Management Flashcards
(156 cards)
1
Q
When is the best time to treat pt receiving hemodialysis
A
Day after they receive dialysis or anytime inbetween their treatment, need platelet count
2
Q
What’s the difference between pts on peritoneal dialysis and hemodialysis
A
Peritoneal dialysis has NO ANTICOAGULATION
3
Q
Pt with moderate renal failure (
A
No contraindication to routine tx
- consult physician to optimize if stage is 4
- use acetaminophen
4
Q
Hyperventilation typical cause
A
ANXIETY
5
Q
Hyperventilation prevention protocol
A
STRESS REDUCTION PROTOCOL (SRP)
- nitrous, increased lidocaine, morning apt, decrease duration
6
Q
How to handle a hyperventilation attack
A
STOP PROCEDURE
- sit patient upright
- comfort
- have pt breathe into something to restore CO2
- reschedule
7
Q
What does an increasing amount of drugs in a hypertensive patient usually indicate
A
The disease is not easily controlled
8
Q
Can you give nitro to hypotension patients
A
NO
9
Q
Dentists role in hypertensive patients
A
Monitor and detect
10
Q
Patient with BP > 180/110
A
Defer elective tx
Only do emergency
11
Q
Does epinephrine need to be modified for hypertensive patients?
A
Yes, modify epi, but still get extremely numb (SRP)
12
Q
If your hypertensive patient is on non-selective b-blockers how do you modify tx
A
Decrease epi, can lead to tachycardia
13
Q
If hypertensive patient is on anti hypertensives?
A
Decrease NSAIDS (use Tylenol?)
14
Q
1 cause of death in Type 2 diabetes
A
MI
15
Q
1 cause of death in type 1 diabetes
A
ESRD
16
Q
What # does HBA1c need to be below
A
7
17
Q
Tx for well-controlled diabetes
A
Any elective care ok- just take glucose levels prior to tx
18
Q
If glucose levels
A
GIVE CARBS- or defer tx
Pt is hypoglycemic
19
Q
If glucose levels are >200 mg/dl
A
DEFER TX
20
Q
What are some things a dentist can do to prevent insulin reaction?
A
- Make sure pt eats and takes insulin prior to apt
- Morning apt
- Have sugar source in office
- Have patient tell you if feeling symptoms
21
Q
Insulin reaction stages
A
- Mild- hunger, weakness, sweating
- Moderate- “snickers commercial” uncooperative, disoriented, belligerent
- Severe- unconscious, tachycardia, hyotensive
22
Q
How do you treat the first two stages of insulin reaction
A
Give oral sugar (cake icing)
23
Q
How do you treat a severe insulin reaction?
A
Call EMS and give glucagon injection
24
Q
What are 3 concerns a dentist would have with an uncontrolled diabetic patient
A
- Infection
- Poor wound healing
- Systemic risk
25
How can a dentist prevent infection in uncontrolled diabetic
Strict glycemic control
26
How can a dentist prevent poor wound healing in uncontrolled diabetic
Avoid elective surgery if HBA1c is >7
27
What can acute odontogenic infection lead to in diabetic patient
LOSS OF DIABETIC CONTROL (or visa versa)
28
What do you do if an uncontrolled diabetic patient comes in with a painful (infected) tooth
EXTRACT IMMEDIATELY
- treat infection aggressively
- don't even need AIc,
- can do I&D and antibiotics also
29
Main objective with heart failure patient
KEEP STABLE- want to leave the same way they came
30
What drug will severe heart failure patients be taking and why is that important for dentists to know?
Digoxin- toxic with epinephrine
31
Signs and symptoms of heart failure
- SOB
- Pitting edema (swollen ankles)
- coughing
- muscle fatigue
32
Tx for compensated heart failure (no SOB even with activity) and decompensated class 2 (SOB only with activity)
elective care ok
- SRP
- chair positioning more upright
- avoid NSAIDS
33
What drugs should you avoid in heart failure patients because it increases fluid retention --> increase BP
NSAIDS
34
What tx can you do for class 3 & 4 heart failure patient (SOB at rest and with light activity)
NO ELECTIVE CARE- SYMPTOMATIC
| - emergency, non invasive ok
35
Stable angina tx (MI >1 mo ago)
Elective care ok
| - SRP
36
What are characteristics of stable angina
- Relieved by rest and nitroglycerin
- precipitated by activity
- unchanged and consistent
37
What are characteristics of unstable angina
- occurs at rest
- inconsistent
- rest and nitro don't relieve
- can lead to MI
38
What tx for unstable angina
Emergency only w/ periodic vitals
39
What can be done prior to emergency tx for unstable angina
Propy of nitroglycerin
40
Emergency protocol for Angina
1. STOP
2. Nitro- 1 spray/tablet every 5 min (up to 3 doses)
3. O2 (2-4L/min)
41
What if patient isn't responding to emergency angina tx
1. Call EMS
2. Chew on aspirin
3. BLS
42
2 types of stents for CV disease
Bare metal- possible restenosis within 6 mo
| Drug-eluding- increased risk for thrombosis for 1 year
43
What drugs are patients on with drug-eluding stents?
Anti platelet therapy for 1 year (Clavix or aspirin)
| ---> BLOODY EXTRACTIONS
44
Can we as dentists stop antiplatelet therapy for patients with stents prior to surgery?
NO
45
What if patient has a pacemaker?
Avoid Using ultrasonic or doing electrosurgery
46
Renal Disease Pt on Hemodialysis
- NO PROPHYLAXIS
- NO BP cuff on AV fistula
- increase bleeding due to platelet destruction so need platelet count (>50,000)
- avoid/adjust nephrotoxic drugs--> use acetaminophen instead
47
Dental tx for well-controlled thyroid disease
Any routine care
-- if increase in Metabolic demand anticipated (extensive surgery) may need more Thyroid hormone, consult PCP
48
Tx for un-controlled thyroid disease
No elective care
- tx infections with PCP
49
Concerns w// uncontrolled hyperthyroidism
Adverse rxn to. Epi
| Infection//wound healing problems
50
Concerns with uncontrolled hypothyroidism
Exaggerated response to CNS depressants
- narcotics and sedatives
- use Tylenol and. Ibuprofen
51
What medication are patients with cardiac arythmias usually on
Warfarin- high risk (ALWAYS NEED. INR)
| Aspirin- low risk
52
What are the most serious risks for arythmias
1- stroke
| 2- heart failure
53
Which arythmia has no. Pulse
Ventricular fibrillation- SERIOUS
54
When should you avoid elective care for arythmia patients
1. High grade AV block
| 2. Sympathetic ventricular rhythms
55
What type of valve. Replacements. Can patients have
Mechanical= lifelong
- on antiplatelet. For life
Bioprosthetic= temporary
-- on antiplatelet for 3 months
56
Do you Prophy for valve. Patients?
YES. BOTH TYPES
| - and previous IE
57
Do. You need INR for. Valve. Replacements?
YES, don't forget to prophy
58
Modifications for well-controlled adrenal insufficiency patient
NONE- all routine care is ok
59
Problems with uncontrolled adrenal insufficiency
May not be able to keep up with metabolic demand
1. Delayed healing
2. Susceptible to infection
3. Intolerant to stress
60
What is the most potent stress activator
Surgery
| - post-op = highest cortisol demand
61
What is given exogenously to adrenal insufficient patients
Glucocorticoids
| - needed for surgery or management of dental infection (contact PCP)
62
What can be done to prevent acute adrenal crisis
SRP
Pre-emptive analgesia (ibuprofen)
Monitor BP (
63
What do you do in an acute adrenal crisis
1. EMS!
2. Position patient in supine position to get O2 to face
3. BLS
64
Patient with active sputum and + TB
NO outpatient to
65
Patient with history of TB
Careful workout to decide what his status of infectivity is currently
66
+ TB test
Chest X-ray to make sure no active TB
| Then routine care
67
What is one condition when you DO NOT give nitrous
Severe COPD
68
What can Rifampin (TB drug) cause
Decrease in WBC
- Increase in bleeding
- Infection
- Decrease in healing
69
Because the cocktail drugs for TB are hepatotoxic what do you need to be worried about?
Drugs that get cleared/metabolized in the liver
| - lower doses of Tylenol (2g/day)
70
2 important roles that are impaired with liver disease
1. Vit K synthesis--> decrease in coagulation factors
| 2. Drug metabolism
71
2 things that can cause cirrhosis
1. Viral
| 2. Alcoholism
72
When do symptoms show up for liver disease?
After the damage has already been done (cirrhosis)
73
Because patients with liver disease are predisposed to bleeding what do you need to know before treatment
PT (if too low no surgery)
74
What are some local Hemostatic measures that can be taken for excessive bleeding with liver disease patients
1. Fresh frozen plasma
| 2. Tx in hospital setting
75
If patient has active Hep C
NO routine to
76
Chronic hep c patient
Routine care ok, consult PCP
77
Bone marrow suppression in liver disease requires what knowledge prior to surgery
```
Platelet count (>50,000)
- maybe use antibiotics for elective surgery because prone to infection (ask PCP)
```
78
Altered drug metabolism in mild/moderate liver disease causes what?
Increased tolerance ---> need larger doses of meds
79
Altered drug metabolism in severe liver disease patients causes what
Increase in unexpected drug effects --> limit Tylenol (2g/day)
80
Dental tx adjustments for stable COPD
- chair positioning (upright)
- local anesthesia (no bilateral blocks)
- avoid nitrous in severe
- avoid anticholinergics and antihistamines (dry out secretions)
81
```
If patient comes in with these S/S
- SOB
- cough
- upper respiratory tract infection
What should you do?
```
This is symptomatic COPD---> reschedule elective tx
82
COPD patients may be taking Theophylline, why is this drug important to know?
Toxic with macrolide and ciprofloxacin antibiotics
83
What can you supplement COPD patients with
O2
84
What else do you need to avoid with COPD because it decreases respiratory drive?
Barbiturates and narcotics (use ibuprofen and Tylenol)
85
Are NSAIDS ok for asthmatic patients?
Ask if they can tolerate them first, may be a trigger
86
Instructions for asthma patients prior to apt
1. Take meds like normal
| 2. Bring inhaler
87
Is nitrous ok for asthma pt?
YES! Use for SRP
88
What do you do if you patient starts to have an asthma attack?
1. Give puff of inhaler every 20 min
89
What if asthma attack is not resolving with inhaler?
Epi pen
- support with O2
- check vitals
- call EMS
90
What are the S/S of asthma attack
- tight chest, coughing, tachypnea, SOB, wheezing
91
What needs to be avoided for Peptic ulcer disease
- NSAIDS or Aspirin (use Tylenol)
| - Corticosteroids
92
S/S of peptic ulcer disease
Epigastric pain
Relief w/ food, milk, antacids
** change in symptom --> worsening ulcer
93
Two types of inflammatory bowel syndrome
1. Crohns
| 2. Ulcerative colitis
94
When should you schedule a patient with inflammatory bowel syndrome?
During remission
95
What drugs should you not give inflammatory bowel syndrome patients?
1. Antibiotics (caution) --> monitor for colitis if have to give
2. Anti-inflammatory
96
Do you need a test prior to surgery for inflammatory bowel syndrome patients?
CBC to evaluative WBC and platelets
97
When do S/S show up for pseudomembranous colitis?
4-10 days after antibiotic given
98
What are S/S of p. Colitis
Diarrhea (watery= mild, bloody= severe)
Severe dehydration
Hypotension
Peritonitis
99
Dental tx of patient with p colitis
Wait until symptom free
| - must have sound reason to prescribe antibiotics (1 Prophy dose is ok)
100
What trimester do you avoid if at all possible
1st (and end of 3rd)
101
What drugs do you avoid in pregnant patients
NSAIDS
Sedatives
Tetracycline
102
What about radiographs for pregnant patients?
FINE! Avoids 1st if possible
103
If pregnant patient suddenly has drop in BP and bradycardia
Baby is probably compressing IVC, have mom lay on her side
104
Transplant patients are _____ for life
Immunosuppressed!
105
What risks do transplant pt's possess
Increased bleeding
Increased risk for infection
Decreased healing (pancytopenia)
106
How long are transplant patients immune system completely destroyed after receiving the transplant?
6 mo post surgery
| - only emergency tx during this time
107
What happens during a dental "clearance" for transplant patients
Diagnosis and treatment of present and potential diseases
| - extremely quick and aggressive
108
During a transplant patients "stable" period what dental tx can be done
"Stable" period= 6+ mo after surgery
- consider which organ was replaced and modify treatment accordingly
- routine treatment is ok just consult transplant team to verify antibiotic prophylaxis etc.
109
What tests are important for dental tx of AIDS patient ?
Platelet and WBC count
Viral load
CD4+ count
110
What level does CD4+ have to drop below to be considered AIDS
200
111
What tx does a symptomatic AIDS pt receive
Emergency only
112
What happens if WBC is
Prophylaxis prior to to
113
Asymptomatic AIDS patient tx
Routine care ok!
114
Asymptomatic AIDS patient with low CD4+
Routine and complex ok!
| - invasive surgery must obtain WBC (>2,000) and Platelet count (>50,000)
115
Concerns for leukemia/lymphoma patients
Increased bleeding
Increased infection risk
Delayed wound healing
.... Same as everything else basically
116
What dental work needs to be accomplished prior to chemo/radiation
All disease/infection eliminated
- must get lab values from oncologist before
- platelet >50,000; WBC >2,000 or PMN >500
117
What if platelets and WBC are below their required values? (>50,000 and >2,000)
Antibiotic Prophy
118
Guidelines for extractions for WBC disorder patients
1. Be prepared to treat bleeding!
2. Extraction done at least 10-14 days before chemo/radiation
3. Primary closure if at all possible
119
dental tx during radiation/chemo
Only emergency and preventive
120
How must you treat a patient with sickle cell TRAIT differently
You don't treat them differently
121
What could cause a sickling crisis
Infection
122
How important is O2 for sickle cell disease patient
VERY- make sure well oxygenated prior to and during surgery
123
What is one key difference in stress reduction protocol for sickle cell disease
Nitrous must have at LEAST 50% O2
124
When should you schedule dental treatment for sickle cell disease patient
During non crisis period
125
What can you give sickle cell patient post op for pain
Tylenol or codeine
126
Sickle cell disease patient comes to your with cellulitis (severe infection)
TREAT INFECTION AGGRESSIVELY
| - could cause a crisis
127
First stage in seizures
Aura- sensory alteration with smell or visual disturbances
| * make sure you know your patients aura
128
Epileptic patient
Routine care
- stress importance of taking meds regularly
- SRP
129
How do you manage a seizure?
1. Stop and take everything out of mouth
2. Passively support pt to prevent injury
3. Returns to consciousness in a few minutes
4. Escort home
130
What time period after a stroke must you be on high alert for S/S of another stroke
Within 6 mo
131
What patients should you not treat regarding stroke?
Unstable patients and recent TIA (mini stroke)
132
Dental alterations for stroke patients
- Just expect to bleed more (no need for platelet count)
- INR for patients on Coumadin
- SRP
- tylenol
133
S/S of a stroke
```
FAST
F- face drooping
A- arm weakness
S- speech difficulty
T- time to call 911
```
134
If there is a platelet problem when will you notice?
Immediately, it will start bleeding and won't stop
135
If there's a coagulation problem when will you notice?
Several hours-days later
| - achieve clot but it's not stable
136
Platelet number that = spontaneous bleeding
137
Coagulation tests
PT and PTT
| - replaced by INR
138
How to treat patient on anti-platelet therapy (aspirin)
NOT TO WORRY!
- just expect some extra bleeding
- DO NOT stop their anti-platelet medication
- local measures to control Hemostasis
139
Patients on anti-coagulant therapy regimen are taking what?
Coumadin (warfarin)- NEED INR
| - pradaxa and xarelto --> don't need INR, more stable drugs
140
What patients can you expect to see on Coumadin/warfarin
- history of MI
- arrhythmia
- valve replacement
- recent drug eluding cardiac stent
- CVA and DVT?
141
For which diseases do you want INR to be 2.5-2.5
1. Mechanical heart valve
| 2. Prevention of recurrent MI
142
for which diseases do you want INR to be between 2.0-3.0
1. Treatment of DVT and PE
| 2. Prevent systemic embolism
143
How long ago can INR be accepted for pre-op evaluation
No longer than 48 hours
144
What should INR be under for surgery/invasive procedures
3.0
145
What happens if INR is too high for dental procedure
PCP must adjust warfarin dosage and patient can come back in about 5 days
146
What are some local measures for hemostasis
- gel foam
- thrombin
- primary closure
147
NSAIDS or Tylenol for bleeding disorders?
Tylenol
NSAIDs can potentiate bleeding
148
What are some instructions for post-op care
No swishing, sucking out of straw, spitting
149
When do you NOT want to do surgery on bleeding disorder patient
Friday's- don't want to bleed over the weekend
150
What do you give pre-op and post-op for type 1 and 2 Von willbrand disease
Pre- desmopressin therapy
Post- aminocaproic acid
- hematologist walks you through all of the genetic bleeding disorders
151
What do you give severe Von willbrand diseaes patients
fresh frozen plasma
Vit k
Factor VIII concentrate
152
Drugs NOT to give patient with bleeding disorder
NSAIDS AND ASPIRIN
153
Hemophilia A patient management
Elective outpatient care normally ok
154
What not to give hemophilia patient
Anesthetic blocks (without management)
155
When do you want to get platelet numbers
1. Bone marrow cancers
2. Dialysis
3. HIV (causes bone marrow suppression)
4. Transplant (")
5. Alcoholism (")
156
Do you need to get platelet #'s for bleeding disorders?
NO- just expect they will bleed
