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BDS3 Special Care Dentistry > Haematology > Flashcards

Haematology Flashcards

1
Q

describe this soft tissue lesion

A

white mottled covering red mucosa of hard and soft palate down to uvula – whole width and depth

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2
Q

difference between candidiasis and leukoplakia

A

candidiasis can be brushed/rubbed off (may cause bleeding underneath)

leukoplakia cannot

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3
Q

radiographic report

A

OPT full mouth

grade A – no overlaps, clear

pathology

  • caries – distal 38
  • periapical – radiolucency of 37, mesial 17, 36
  • bone – use BSP flowchart – distal 38 is in middle 1/3 (50%/65 = 0.7)
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4
Q

dx perio

age 65 male

smokes 5 daily

21 units of alcohol per week

diabetes

A

use BSP flowchart

bone – distal 38 is in middle 1/3 (50%/65 = 0.7)

Generalised perio, stage 2, grade B (smokes, diabetes, OH)

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5
Q

dx this soft tissue lesion

white slough in his palate over the past few weeks

‘the blood pours out of my palate’

A

Pseudomembranous Candidosis

  • fungal infection
  • opportunistic – medication; smoking; dry mouth (medications), denture wearer if not good denture hygiene, steroid inhalers, nutritional deficiencies

undertake investigations until potential causative factors - local or generalised

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6
Q

local factors for candidosis infection

A

antibiotic use

dentures

local corticosteroid use

xerostomia - drug induced; radiotherapy induced

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7
Q

general factors for candidosis infection

A

drugs

extremes of age

endocrine - Cushing’s sydrome; diabetes mellitus

immunodeficiency - heriditary, acquired

nutritional deficiences - Fe

smoking

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8
Q

explain possible causes for wide spread caries

pt retired, diabetic, poor OH

A
  • Has a higher and frequent intake of cariogenic foodstuffs
  • Performs oral hygiene once daily
  • May have a dry mouth due to medications and diabetes
    • can be worsened by role of caffeine in tea and coffee (acknowledge as a diuretic)
      • significance of this role is dependent upon a number of other factors but may be worsen the situation if consumed in excess
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9
Q

what is dx for 37

A

periapical periodontitis

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10
Q

atrial fibrilation link to oral health

A

can result in complications

  • pulmonary embolism PE
  • deep vein thrombosis DVT
  • cerebrovascular accident CVA/stroke
  • myocardial infarction (heart attack)

pts in AF are anti-coagulated if cardioversion is not indicated or unsuccessful

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11
Q

diabetes link to oral health

A
  • risk hypoglycaemic episode – medical emergency
  • periodontal disease
  • delayed healing
  • salivary gland dysfunction
  • oral dysesthesia
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12
Q

hypertension link with other medical conditions

A

significant risk factor for several medical diseases:

  • heart disease
  • heart attacks
  • strokes
  • heart failure
  • peripheral arterial disease
  • aortic aneurysms
  • kidney disease
  • vascular dementia
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13
Q

warfarin and apixaban

A

are anticoagulants (apixaban is NOAC)

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14
Q

warfarin mechanism

A

vitamin K antagonist

  • anticoagulant for atrial fibrillation (irregular heartbeat)
    • reduce risk of stroke
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15
Q

NOAC benefits

A

means no regular blood tests

  • Good for pts, less monitoring needed
  • More complicated for extractions

e.g. apixaban

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16
Q

simvastatin

A

HMG CoA reductase inhibitors

  • Used to treat hypercholesterolaemia
  • May have interactions with other drugs that you may prescribe
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17
Q

furosemid

A

Loop diuretics

  • Used in combination with other hypertensive medications to control resistant hypertension

Can exacerbate diabetes – however less risk of hyperglycaemia when compared to thiazide diuretics

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18
Q

carvedilol

A

Beta blocker

  • When used in hypertension management – its not first line Tx (so not responding well)

Individuals on non-selective beta blockers – heightened sensitivity to effects of vasopressors in LA

  • Cause increase vascular resistance with a subsequent increase in BP – MEDICAL EMERGENCY
    • MI and stroke can occur

Risk is small in dentistry – prevented by appropriate drug selection and LA technique

  • Use adrenaline free
    • Harder to achieve haemostasis but safer
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19
Q

insulin for diabetic

A

Prescription indicates that he is dependent upon replacement insulin

Additionally, consider timing of appointments

  • Ensure blood glucose levels are appropriate for treatment and not coincide with time of peak insulin activity as causes risk of hypoglycaemia
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20
Q

metformin hydrochloride

A

Has an anti-hyperglycaemic effect

Recommended as first choice for initial treatment for all patients with diabetes

  • positive effect on weight loss
  • reduced risk of hypoglycaemic events
  • long term cardiovascular benefits associated with use
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21
Q

any changes in blood can lead to

A

clot risk

  • stroke
  • DVT
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22
Q

hypertension

key things to know prior to carrying out any dental tx

A

Need to know stage

  • Uncontrolled hypertension may need to be controlled before the delivery of dental treatment

Hypertensive crisis is a medical emergency (>180/110)

If dental anxiety is a trigger for a significant dangerous increase in blood pressure – maybe consider sedation

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23
Q

hypertensive crisis

A

>180/110

medical emergency

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24
Q

diabetes

key to know before dental tx

A

Establish diabetic control – inform diagnosis and stage dental Tx

HbA1c test is an average of last 3 months sugars

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25
Q

would you provide any tx to pt with this history who provided this history only

Atrial Fibrillation, Diabetes, Hypertension

currently on Warfarin scheduled Apixaban

Other meds: Simvastatin, Furosemide, Carvedilol, Insulin, Metformin

A

Complex medical history

Many issues raised that you need more information on before providing any operative treatment

  • Risks of dental treatment
  • Measures needed to ensure safety of pt

today provide intial preventative tx

  • long term maintenance of oral health
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26
Q

what to get before doing any potential invasive bleeding risk procedures on warfarin pt

A

INR

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27
Q

warfarin and candidosis

A

warfarin interacts with antifungals - need to manage - liaise with GDP

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28
Q

why may this pt have a candidosis infection?

65 yo male

Atrial Fibrillation, Diabetes, Hypertension

currently on Warfarin scheduled Apixaban

Other meds: Simvastatin, Furosemide, Carvedilol, Insulin, Metformin

A
  • Diabetic control
  • Implication of medications
  • May also have anaemia
  • Missing teeth – likely wear RPD (esp as business man) – can be local factor
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29
Q

management of candidosis

A

Candida exist in biofilm

  • Observe principles of biofilm management and consider mechanical disruption
    • Increase in resistance to candida to drug therapies
  1. Use a toothbrush or gauze to clean palate – can be supplemented with short term use of Corsodyl mouthwash or gel
    * Clean damp toothbrush – will be sore and inflamed
  2. Denture hygiene observed
  • Remove denture at night
    • Clean – over sink filled with water, with toothbrush and liquid soap or effervescent tablets, rinse
    • Leave out as much as possible until candida clear – can penetrate denture, may need new one
  • Topical gel can be used to line RPD

If first line management fails – consider medications but

  • Pt systemic health
    • Interactions with Warfarin
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30
Q

Fluconazole capsule interactions (Common)

A

warfarin - impact INR
statins - muscle aches and pains

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31
Q

nystatin

A

topical antifungal

liquid - rinse and spit, 4 times a day

local, strong effect

safe to use on warfarin pts

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32
Q

miconazole

contraindications

A
  • Contraindicated in pts taking warfarin
    • it potentiates the anticoagulant effect
  • Contraindicated in statins
    • increased risk of myopathy
33
Q

staged management of pseudomembranous candidosis

A

start with local agent (nystatic, miconazole)

go to systemic agents as final option (fluconazole)

34
Q

INR

A

International normalised ratio

  • Blood test particularly useful for pts on warfarin
  • Prothrombin time (PT; time for plasma to clot) of pt divided by a reference PT value

Normal healthy individual is 1

For warfarin patient there is target ranges

  • Below 4 happy to extract

Ideally within 24 hours of appointment

  • If stable, maybe longer
    • not stable if other sig risk factors – poor control diabetes etc, new pt)
35
Q

target healthy INR

A

1

36
Q

warfarin INR range

A

below 4 happy to do dental extraction

37
Q

INR calculation

A

prothromin time (PT - time for plasma to clot) or pt

divided by

reference PT value

38
Q

INR change due to (4)

A

diet - cranberry, grapefruit, pomegranate

medications - amoxicillin, warfarin level

hormones

stress

39
Q

SDCEP

INR for safe to extract for warfarin pt

A

below 4

40
Q

if INR is taken at 3 daily intervals indicates

A

Very frequent

Not stable

  • Unpredictability – how safely can he be managed
  • Need INR at least 24 hours before procedure but ideally as close as possible
41
Q

what does a variance in INR in short time frame indicate

A

Warfarin control not as good as it could be

  • higher risk of complications
    • Post-operative bleeding

Can be due to changes in lifestyle, stress, drink and diet, medications (antibiotics)

42
Q

7 considerations to limit the risk of bleeding if there is many teeth to be extracted for a haematological pt

A
  1. If the drug regime is short or long term – if it is short term only can the treatment be delayed
    * His warfarin use is life long
  2. Plan the treatment for early in the day or week to allow time for management of any complications
  3. Undertake an atraumatic technique to dental extractions and surgery
  4. Use appropriate measure to establish haemostasis
  5. Consider the staging of treatment by limiting the initial area of surgery and evaluating haemostasis before processing, utilise haemostatic adjuvants and post-operative monitoring
  6. Advise on the use of paracetamol analgesia (unless contraindicated) instead of NSAIDs
  7. Provide full written instructions and emergency contact details
43
Q

how to prevent excessive bleed peri-operatively

A

Cotton wool to help stop bleed – don’t leave in as infections risk

PACK – matrix/mesh for clot to form around

  • Blood more stable
  • Less change of breakdown
  • Can help haemostasis

Surgicel or caltistat

44
Q

post op extraction instructions

A
  • rest - avoid physical exercise or manual labour that will cause increase in blood flow for 24 hours
  • Avoid eating on that side
    • Avoid too hot/ too hard
  • Avoid smoking for as long as possible
  • Avoid rinsing mouth
    • wait at least 6 hours, ideally 24
      • After lunch – if extracted first thing
      • After dinner - if midday extracted
    • Gentle warm salty water to bathe area – tip head back

Bleeding – provide gauze to bite on, if used use clean kitchen roll/towel/cotton wool bite for 20 mins – time

  • Emergency contact number if unable to stop bleeding after 20 mins
45
Q

requirements for warfarin extraction pt prior to app

A

Planning:

  • appointment early in the day and early in week to allow appropriate time for review

Check INR:

  • preferably 24 hrs before extraction but acceptable up to 72 hours where the INR is stable
46
Q

local measures to achieve haemostasis

A

LA

haemostatic aids

sutures

pressure

atruamatic technique

tranexamic acid mouthwash

47
Q

tranexamix acid mouthwas

A

acts as a local antifibrinolytic agent is not routinely recommended in primary care

48
Q

3 local haemostatic aids to pack socket with

A
  • Oxidised cellulose (Surgicel)
  • Collagen sponge (haemocollagen)
  • Resorbable gelatin sponge (spongostan
49
Q

suture options

A
  • Resorbable (catgut or synthetic (polyglactin, Vicryl) – preferable as they attract less plaque
  • Non-resorbable (silk, polyamide, polypropylene) – remove them after 4-7 days
50
Q

LA use for haemostatic aid

A

Containing vasoconstrictor should be administered by infiltration or by intraligamentary injection where practical (close to surgery site)

  • Short 27 gauge needle to minimise tissue damage

Regional nerve blocks avoided when possible – if no alternative, administer LA cautiously with aspirating syringe

51
Q

4 NOACs

A

apixaban

dabigatran

edoxiban

rivoroxiban

52
Q

apixaban

mechanism of action

A

Factor Xa Inhibitor

test chromogenic anti-Xa assays

53
Q

edoxiban

mechanism of action

A

Factor Xa Inhibitor

test chromogenic anti-Xa assays

54
Q

rivoroxiban

mechanisms of action

A

Factor Xa Inhibitor

test chromogenic anti-Xa assays

55
Q

dabigatran

mechanism of action

A

direct thrombin inhibitor

test - diluted thrommbin time (dTT); Ecarin-based assays such as ecarin chromogenic assay (ECA)

56
Q

benefits of NOACs (6)

A
  • predictable pharmacokinetics and pharmacodynamics
  • rapid onset and offset - short half life
  • low drug-drug and food interactions
  • no dietary restrictions
  • in general, no need for labratory monitoring (some cases need)
  • wide therapeutic window
57
Q

5 weaknesses of NOACs

A
  • do not exist standardised test for monitoring of NOACs, when it is necessary to monitor them e.g. hepatic or renal disease
  • sometimes rapid offset and short half life may be considered disadvantage
  • currently lack antidote
  • high cost
  • not enough experience
58
Q

if pt requires a single tooth extraction and takes Apixaban twice daily

how to go about

A

follow SDCEP guidance

  1. Evaluate and classify risk
    * Refer to SDCEP – low risk of post-op bleeding complications (as simple extraction of single tooth)
  2. Change drug regime as necessary
    * Check guidance for alteration in drug scheduling – not needed as NOAC dose schedule changes is only needed in higher risk bleeding complication pts
59
Q

if pt requires 4 teeth in lower right quadrant to be extracted and takes Apixaban twice daily - how to manage it

A

refer to SDCEP guidance

  1. Classify risk
  • More than 3 teeth
    • Flap raised
    • higher risk of post operative bleeding
  1. Dose schedule
  • Need changed as higher risk
  • Takes twice daily – ask him to not take morning dose and take at usual evening time
    • consult medical colleague
60
Q

how to determine bleeding deficiency and severity if pt attends haemophilia centre

A

blood tests registered

61
Q

haemophilia A

A

deficiency of factor VIII, most common (85% of all cases)

62
Q

haemophilia B

A

deficiency of factor IX

63
Q

difference between haemophilia A and B

A

Both forms are X-linked recessive conditions and can only be differentiated through coagulation factor assays

(A - VIII deficient, B - IX deficient)

64
Q

severity of haemophilia

A

is a spectrum

  • Severe = <1% factor present
  • Moderate = 2-5% factor present
  • Mild = 6-40% factor present
65
Q

what could be causing this is pt who attends a hamophilia centre trips and falls into surgery

A

significant swelling of right knee

haemophilia and coagulation unit – alarm

  • Manage issue swiftly – take priority over any dental Tx

Likely to be hemarthrosis

  • Bleeding in joint space and is associated with haemophilia
  • Damage to articular cartilage within the joint is common consequence of repeated hemarthrosis
    • Intraosseous haemorrhage may lead to bone resorption and the development of bone cyst
66
Q

clincal dx from radiograph

A

Periapical periodontitis 18, 26, 46, 47

Caries 18, 17, 27, 28, 47

Retained roots 26, 46 and 48

Chronic generalised periodontitis

67
Q

haemophila considerations for dental care

A

Examinations and treatments that do not require manipulation of mucosa are safe to deliver to pts in this condition

Delivery of supragingival restorations, crowns and bridges with the use of infiltration anaesthesia is safe to provide for people with haemophilia in GDP

  • dental extractions, surgical procedures, subgingival scaling or anaesthesia requiring IANB – need a dental clinic associated with haemophilia centre
    • Increased risk of bleeding
      • Require medical prophylaxis and monitoring
    • Consider articaine infiltration and intraligamentary injection to avoid IANBs
68
Q

DDAVP (desmopressin)

A

used in mild haemophila and von Williebrand’s disease

undertaken before dental procedures which inc bleeding risk

69
Q

moderate and severe haemophila need before risk bleeding in dental procedure

A

factor replacment likely

70
Q

mild haemophila and von williebrand disease before bleeding dental procedure

A

DDAVP (desmopressin) may be sufficient

71
Q

factor replacement impact on dental tx plan

A

want to reduce the number of times any pt exposed to factor replacement

  • Risk of local site infection
  • Risk of inhibitors/ antibodies developing
  • Cost
  • Risk of blood borne infections if plasma derived factor is used although blood products are comprehensively screened
72
Q

4 reasons why want to reduce number of times pt needs factor transfusion replacement

A
  • Risk of local site infection
  • Risk of inhibitors/ antibodies developing
  • Cost
  • Risk of blood borne infections if plasma derived factor is used although blood products are comprehensively screened
73
Q

tranexamic acid

A

antifribrinolytic agent

can be used in management of haemophiliacs

74
Q

dental factors to consider when building tx plan

A
  1. Previous dental experience
  2. Risk factors and potential for modification
  3. Oral hygiene and use of fluoride
75
Q

tx should be in stages

A

short term

medium term

long term

76
Q

short term tx plan should include

A

acute management - pain, swelling

prevention

stabilisation of disease

77
Q

what to do if haemophiliac presents who has not been to centre for many years but requires tx due to facial swelling

A

not been tohaemophilia unit for many years – no up to date test results

Thus indicated to provide course antibiotics until appropriate assessments and planning can be made in conjunction with haemophilia unit

78
Q

what should the approach to dentistry be if pt requires medical agent to be treated (e.g. platelet transfusion)

A

quadrant approach - do all tx in that quadrant that could cause bleeding risk (extractions, subgingival scaling etc)

minimise number of apps so need to for multiple exposures to medical agent

79
Q

mid to long term tx plan should contain

A

prvention

re-evaluation of disease status (e.g. periodontal condition) and manage as required

restoration of spaces as needed

BDS3 Special Care Dentistry (21 decks)

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