med complex management

Question 1

precautions to take in patients with uncontrolled hypertension

Answer 1

avoid cox 2
avoid nsaids
avoid azoles with statins
avoid macrolides with ccb
caution vasoconstrictor eg avoid adrenaline containing retraction cord, topical vasoconstrictor for hemostasis
avoid intraligamentary, intraosseous, iv injection
aspirating syringe

Question 2

what medication should i not give a patient who has recently undergone CABG

Answer 2

cox 2 inhibitors
nsaids
macrolides
azoles

Question 3

how long to defer treatment by after cabg or ptca

Answer 3

3-6 months
defer by 1 year for elective surgical procedure

min 6 weeks for bare metal stent
6 months for drug eluting stent

Question 4

how long to defer treatment by after AMI

Answer 4

3 months for routine treatment
6 months for invasive treatment, GA

Question 5

precautions to take for a patient post ceid insertion

Answer 5

avoid diathermy electrocautery mri due to electromagnetic interference

defer by one month post insertion, ensure functional capacity is adequate

no antibiotic prophylaxis is required

avoid bupivacaine

caution vasoconstrictors

Question 6

Patient is on clopidogrel for hypertension management. Needs to do extraction. What pre op planning needs to be done

Answer 6

Do not stop anti platelets

Question 7

max dosage of adrenaline for patient with uncontrolled hypertension

Answer 7

0.04mg

Question 8

why do we avoid azoles and macrolides in patients with htn

Answer 8

macrolides inhibit cytochrome, causing accumulation of statins and ccbs

azoles can increase the risk of statin associated myopathy

Question 9

what is an acute hypertensive crisis

Answer 9

sudden severe increase in bp to ≥180/120mmHg

Question 10

what should you check for if you suspect acute hypertensive crisis

Answer 10

dyspnea – pulmonary edema
chest discomfort – MI, aortic dissection
neurological deficit – stroke
nausea and vomiting – increased intracranial pressure

Question 11

can you treat a patient with chest pains

Answer 11

Unstable angina eg occurs at rest, unresponsive to GTN – do not do elective dental treatment

stable angina eg only on exertion, relieved with rest and medication – treat with precautions such as stress reducing protocol, caution vasoconstrictor, avoid NSAIDs and COx2 inhibitors, GTN on standby

Question 12

how long to defer treatment by afeer MI

Answer 12

if patient is deemed low risk, non invasive treatments can be deferred by 60 days

otherwise, non invasive treatment should be deferred by 3 months

invasive, surgical procedures should be deferred by 6 months

Question 13

what medication is a patient on 3 months after PTCA? and what is my management?

Answer 13

dual anti platelets (high risk of stent thrombosis within first year of placement)

do not stop anti platelets, current recommendation is to not modify, though some may continue with aspirin and stop other anti platelet

avoid elective care for 6 months to 1 year. consult cardio for invasive procedure

> 3 exo, do over multiple visits

Question 14

patient on dual anti platelet therapy will need to undergo major dental surgery. what to do?

Answer 14

stop p2y12 inhibitor 5-7 days prior to surgery, continue with aspirin unless bleeding risks prohibitive

restart 3 days after surgery

Question 15

can i do routine dental treatment for a patient with an arrythmia?

Answer 15

yes (with stress reducing protocols, pain control, monitor pulse rate and pressure)

however, in some situations, treatment should be deferred
- symptomatic
- pre existing cardiac disease
- high grade av block
- ventricular arrhythmia
- supraventricular arrhythmia with uncontrolled ventricular rate

Question 16

why do i need bleeding precautions in a patient with cardiac arrhythmia?

Answer 16

may be on warfarin or dabigatran or rivaroxaban due to increased risk of stroke

Question 17

what medication to avoid in patients with cardiac arrhythmias

Answer 17

macrolides
azoles
bupivacaine

Question 18

what does chads2 score mean

Answer 18

measures the thromboembolic risk in a patient with non valvular atrial fibrillation

congestive heart failure
hypertension
age>75
diabetes
stroke/tia

Question 19

can i treat a patient with congestive heart failure?

Answer 19

nyha 1 and 2 can be treated. nyha 3 and 4 (marked limitation or unable to carry out physical activity) should not receive elective treatment

simplify treatment

bleeding precautions

minimise vasoconstrictors

avoid erythromycin, tetracycline if on digoxin

avoid nsaids, cox 2 inhibitors, corticosteroids (fluid retention)

consider terminating procedure if patient starts getting breathless

avoid supine position

Question 20

signs of poor compensation for congestive heart failure

Answer 20

paroxysmal nocturnal dyspnea
orthopnea
dypsnea on exertion at level of activity that is usually well tolerated
peripheral edema
fluctuating body weight

Question 21

when do symptoms of infective endocarditis develop

Answer 21

2 weeks after procedure

Question 22

signs of infective endocarditis

Answer 22

fever in the presence of risk factors
- previous ie
- recent dental or surgical procedure
- congenital heart defect
- immunosuppression
- injection drug use

heart murmur

persistent bacteremia

immunological and emboli phenomenon

oral petechiae

Question 23

conditions requiring antibiotic prophylaxis for prevention of infective endocarditis

Answer 23

previous ie
unrepaired congenital cyanotic heart defect
congenital heart defect repaired with prosthetic patch or device with residual defect, or within 6 months of procedure
prosthetic heart valve
prosthetic material for heart valve repair
cardiac transplant with with valve regurgitation due to abnormal structure of valve

Question 24

how is antibiotic prophylaxis given

Answer 24

amox 2g 1h before procedure
if allergic to amox, cephalexin 2g or azithromycin 500mg or doxycycline 100mg

Question 25

what guidelines should be followed if multiple rounds of ab prophy needed

Answer 25

1 month before 2nd dose of same antibiotic 10-14 days interval for alternating antibiotic regime

Question 26

precautions that should be taken for a patient with asthma

Answer 26

should use regular asthma medication several days before and after dental treatment consider prophylactic puff before procedure bring inhaler to appointment avoid nsaids, cox2 inhibitors, aspirin, macrolides and ciprofloxacin wtih theophylline, avoid narcotic analgesics with benzodiazepine avoid ga treatment best done in the late morning or early afternoon short appointments with frequent rests consider terminating treatment if becomes dyspneic

Question 27

how to assess whether patient's asthma is suitably controlled to tolerate dental treatment

Answer 27

≥80% peak expiratory flow rate

Question 28

when can a pregnant person get dental treatment

Answer 28

best to do treatment in 2nd trimester or early 3rd elective dental treatment should be avoided in the first trimester

Question 29

what medication to avoid in pregnant women

Answer 29

aspirin, nsaids (ductus arteriosus closure, adverse events associated at third trimester) tetracycline drug administration should generally be avoided in pregnancy, especially in the first trimester

Question 30

what analgesic can i prescribe a pregnant woman

Answer 30

acetaminophen/paracetamol

Question 31

what antibiotics can i give a pregnant woman

Answer 31

amoxicillin, cephalexin, clindamycin , erythromycin, penicillin

Question 32

what is well controlled diabetse

Answer 32

hba1c < 7% routine dental treatment and minor oral surgery procedure can be carried out in well controlled diabetics

Question 33

when do i need to prescribe supplemental steroids prior to procedure, and how is it administered

Answer 33

stressful procedure eg extensive procedure, oral surgery patient is currently on systemic steroid on systemic steroids ≥7.5mg in the past 2 weeks to one month on systemic steroids for more than one month in the past year administration: within 2 hours before LAOP, take double regular dose of oral steroids, or 25-50mg IV hydrocortisone hemisuccinate for minor surgery

Question 34

in a patient with untreated hypothyroidism, avoid use of

Answer 34

cns depressants eg narcotic analgesics, barbiturates

Question 35

management of hemophiliac patient

Answer 35

consult hematologist and determine severity of disease, level of factor correction if required patient may require pre op transfusion of 50-100iu/dl factor 8 or 9 local hemostatic measures eg antifibrinolytic agents such as tranexamic acid, surgicel prolonged observation avoid nsaids, aspirin. use acetaminophen +/- codeine for analgesia

Question 36

management for patient on single anti platelet therapy prior to minor oral surgical procedure

Answer 36

modification not required if major bleeding is anticipated, drug holiday is needed. 7 days preop and 3 days post op; aspirin only 3-5 days pre op required

Question 37

following acute venous thrombosis episode, how long should dental treatment be deferred for

Answer 37

patient should have received 3 months of anticoagulation (min 1 month)

Question 38

guidelines for how to proceed with patient on warfarin

Answer 38

check inr <2.5 safe to proceed with routine dental treatment such as simple extractions, with the use of local hemostatic measures 2.5-3.0 refer to OMS >3.0 refer for reversal, defer until INR controlled. consult medical physician.

Question 39

options for warfarin reversal

Answer 39

decrease in dosage bridging IV heparin therapy bridging LMW subc heparin stop for 3 days prior to procedure, take inr on the day of procedure. stop heparin 6-18 hours prior to procedure. restart warfarin 12-24 hours after surgery. heparin min 4 days as warfarin takes 96 hours to reach peak effect in case of emergency, fresh frozen plasma, vitamin k, prothrombin complex concentrate

Question 40

drug interactions with warfarin

Answer 40

nsaids, aspirin, tramadol, metronidazole, erythromycin, doxycycline, corticosteroids potentiate bleeding barbiturates and carbamazepine inhibit warfarin, putting patient at risk of clotting

Question 41

pre operative local hemostatic measures

Answer 41

vasoconstrictors

Question 42

intra op local hemostatic measures

Answer 42

thorough curettage to remove granulation tissue atraumatic procedure

Question 43

post op local hemostatic measures

Answer 43

pressure suturing TXA (antifibrinolytic agent) local hemostats eg gelatin sponge, oxidised cellulose poig

Question 44

how to discontinue heparin bridging after procedure

Answer 44

continue heparin for minimum of 4 days as peak antithrombotic effect of warfarin is delayed 96 hours, until INR reaches desired range

Question 45

what patients are at high risk for bleeding

Answer 45

known bleeding disorders eg clotting factor defects abnormal blood parameters despite no known bleeding disorders ** anti coag and anti platekets are moderate risk

Question 46

dental surgery can be performed how many hours after heparin dose

Answer 46

Ufh: 6-8h LMWH: 18-24h

Question 47

management of patients on noacs eg dabigatran, rivaroxaban

Answer 47

no reversal agent for minor surgical procedures, do not alter. but avoid performing surgery at peak activity (2-3h after dose) for major surgical procedures, consider cessation for 24h avoid medications that can affect anticoagulation effect. erythromycin, nsaids, clopidogrel can increase anticoagulation in dabigatran nsaids can increase anti coagulation in rivaroxaban

Question 48

what are the various laboratory tests available to test hematologic parameters

Answer 48

FBC - platelet, rbc, wbc PT - extrinsic pathway, warfarin ApTT - intrinsic pathway, heparin, hemophilia INR - standardised PT time, measure extrinsic pathway Bleeding time - time from onset to first arrest of bleeding

Question 49

what are the considerations in treating a patient with hepatic disease?

Answer 49

bleeding tendency (production of coagulation factors), need local hemostatic and possibly systemic hemostatic measures impaired drug metabolism -- nsaids, paracetamol, lidocaine, mepivacaine hepatotoxic drugs eg clarithromycin defer elective treatment in patients with decompensated liver disease eg present with jaundice

Question 50

considerations for patient with renal disease

Answer 50

avoid nephrotoxic drugs impaired metabolism eg amoxicillin on anti thrombotic medication during hemodialysis (LMWH, defer procedure 12h after last dose) platelet destruction during hemodialysis schedule appt outside of dialysis days

Question 51

oral manifestation of hiv/aids

Answer 51

linear gingival erythema kaposi sarcoma oral hairy leukoplakia oral candidiasis nug

Question 52

management of patient undergoing active chemotherapy

Answer 52

patient is very immunosuppressed emergency dental treatment only, consider need for ab prophy do nothing + prescribe antibiotics oral manifestations

Question 53

timing of dental management for epileptic patients

Answer 53

anti convulsants 2-3h prior to procedure avoid elective dental procedures in patients with poorly controlled seizures (>1 per month), hospital based if necessary avoid if lethargic, behavioural changes

Question 54

intraoperative precautions for epileptic patients

Answer 54

strong suction avoid multiple cotton rolls avoid precipitators mouth prop

Question 55

medications to avoid in patients with epilepsy

Answer 55

increased bleeding risk due to action of valproic acid on platelets, avoid nsaids and aspirin avoid tramadol as can precipitate seizures avoid macrolides in patients taking anti convulsants long term aed use can cause osteoporosis, caution oms caution paracetamol -- hepatotoxicity as side effect of AED