Flashcards in Oral Medicine IV - the Brennan Mystery Deck (75):
Normal BP/Dental Tx/Referral
< 120/80 Any No
< 140/90 Any Encourage pt see PCP
< 160/100 Any Encourage see PCP
< 180/110 Intraoperative monitoring Prompt Referral
> 180/110 Defer refer ASAP (symptomatic=immediate)
When would you consider Intraoperative monitoring for HTN?
between 160/100 and 180/110
If symptomatic, refer when?
2 Follow-up questions for HTN:
Did you take meds today?
Do you know your normal baseline limit?
Example of non-selective Beta Blocker:
Max limit of epi if on this:
Max limit levonordefrin:
If a pt is taking a Thiazide Diuretic, what is the Vasoconstrictor (epi) limit?
Non-selective Beta blockers block...
If on non-selective...
Beta 1 and Beta 2
Beta 1 only
If pt forgot to take meds and no Emergency...
If pt has altered/high BP, ask what?
Did you take meds today?
If a pt forgot to take their HTN meds, you can assume if they take them it will....
Put them back in normal range
JNC8, if older than _____, SBP should be _____
If younger than _____, SBP should be _____
CKD or Diabetes, SBP should be _______
60 < 150
If pt has had an MI, know what?
We won't Tx if less than ______ unless absolutely necessary
probably want what?
Coronary Artery Disease and MI, what is important?
2 ways to accomplish:
Stress reduction - Anxiolysis
Premedicate and pain control
CAD/MI, use what 2 methods to premedicate?
When is it inappropriate to do a medical consult?
Confirmation med Rx nothing to do w/ scenario
What is the best regimen to Mitral Valve Prolapse Prophylaxis?
AHA guidelines, premedicate for what 4 conditions?
Artificial Heart Valves
Hx Infective Endocarditis
Cardiac Transplant w/ Valvulopathy
What are the 3 Congenital Conditions requiring premedication via AHA guidelines?
Unrepaired/incompletely repaired Cyanotic HD (including palliative shunts/conduitis)
Completely repaired defect w/ Prosthetic matl/device first 6 months after procedure
Repaired w/ residual defect at site/adjacent to site of Prosthetic patch/device
5 Examples of when Not to Premedicate:
(needed in the past, not now)
Mitral valve prolapse
Bicuspid valve disease
Calcified aortic stenosis
Congenital - ventricular/atrial septal defect, hypertrophic cardiomyopathy
5 Dental procedures that do not require Abx prophylaxis (if Infective Endocarditis, etc)
Anesthetic through non-infected tissue
Shedding deciduous teeth/bleeding trauma oral mucosa/lips
PRJ (prosthetic Joint replacements), follow what guide?
AUC (appropriate use criteria)
The AUC was created to Tx what two groups?
6 types Immunocompromised pts:
AIDS (CD4 < 200)
Immunosuppressive chemo w/ neutropenia
RA using TNF alpha or Prednisone > 10 mg/day
Organ transplant immunosuppressants
Marrow transplant (pre/post graft or posttranslplantation)
AUC criteria can be immunocompromised or preiprosthetic/deep ______
Prosthetic Joint Replacement
3 types of AUC recommendations:
Limited: evidence quality unconvincing
Inconclusive: lack of evidence
Consensus: Expert opinion supports recommendation even though there is no empirical evidence that meets inclusion criteria
When would we prophylax for Pins/Plates/Screws?
Does pt preference matter for BisPhosphonate premed?
"pt preference should have a substantial influencing role"
Tx guidelines for Oral Antiresorptive Meds: Elective Tx:
Inform there is a small risk of developing what?
If pt is on the drug for less than 4 years...
If pt is on the drug for less than 4 yrs w/ Prednisone...
If pt is on the drug for more than 4 years...
MRONJ (less than 1%)
no alteration/delay for Tx
consider: 2 mo prior/3 mo post Drug holiday
2 prior/3 post Drug holiday
MRONJ is Worse: Cancer vs Osteoporosis:
IV meds vs Oral meds
> 4 yrs vs < 4 yrs (duration)
mandible vs maxilla
greater than 4 years
Even though MRONJ is worse w/ Cancer, IV meds, Dentoalveolar surgery, greater than 4 yrs duration BisPh's, and in the Mandible... risk is still very low
Risk of MRONJ is worse w/:
*Mandible is worse
If pt has a cirrhotic liver, ask about...
hemostasis and susceptibility to infection
Liver function tests for Hemostasis (2 of them)
Hemostasis tests for Liver function, Platelet count should be:
INR should be:
greater than 50,000
less than 3.5
*for most surgical procedures
Liver function, infection susceptibility, Neutrophil less than what requires Abx prophylaxis?
< 0.5 or 500 mm3
* (depending on units)
If liver disease, avoid what analgesics?
Use what/limit to what dose?
Opioids should be used short term at _____ intervals (liver conjugates)
LA below ___ mg/kg w/ epi
Avoid ___ w/ EtOH
Acetaminophen, less than 4g/day
Medical Consult w/ Liver Disease, you need to confirm what 2 things?
Need to Evaluate Liver function tests (ALT/AST, bilirubin, alkaline phosphatase) if ______ is 4x normal
Platelets greater than 50,000
INR less than 3.5
GERD, avoid what 2 drugs?
Tx enamel erosion, use what Fluoride Tx?
Use what rinses?
topical, varnish, custom trays
Mild baking soda (1 teaspoon in 8 oz water)
DDI to know for GERD:
Cimetidine (antacid) inhibits absorption of Ketoconazole (antifungal)
Chronic Kidney Disease: Stage 1/GFR
greater than 90
less than 15
Chronic Kidney Disease, when to monitor pt, ensure stability and Tx, no other mods
Medical consultation necessary
Stage 3 and below (30 or better GRF)
Stage 4 or higher (29 and below)
When we get a medical consult one of the key things we need to know is Kidney Function
Pt on Dialysis, 5 things to know if in Dental Chair:
Increased tooth loss
Perio associated w/ C-reactive protein - major risk factor for CKD
Excess bleeding - get platelet count
Anemia - need Hb/Hematocrit prior to Nitrous
Tx on non-dialysis days
There are no contraindications to Tx if pt on _____ dialysis
AV site w/ pt on Dialysis:
No IV/IM meds on that arm
Take BP on other arm
Dialysis pts have increased susceptibility to infections
Infective Endocarditis of ____ % incidence
*follow AHA guidelines
pt has BP 173/103, what guidelines?
Any Tx, consider monitoring BP intraoperatively
*b/c Stage II HTN
Coughing up blood
Shortness of breath while lying flat
Exercise induced cramping
dark blood in stool
Fresh blood through anus
blood in urine
excessive urination at night
lots of urine (dilute)
Ideally BisPh's should be Rx after dental consult b/c much better to have extractions done before
What is the most common primary diagnosis in the US?
15-20% of pts have?
white coat HTN
Amoxicillin is Oral and ___g prior to Dental procedure
If unable to take oral, ____ or ______
Allergic to Penicillin - ORAL (3 drugs)
Allergic to Penicillin/Unable to take oral
Ampicillin (2g), Cefazolin/Ceftriaxone (1g)
Cephalexin (2g), Clindamycin (600mg), Azithromycin/Clarithromycin (500mg)
Cefazolin/Ceftriaxone (1g), Clindamycin (600mg)
2 Oral Bisphosphonates and 1 Oral/IV
Ibandorate (Bonive) can be both
What Heps tend to self resolve?
Which are more serious?
A and E
B, C, D
Pts w/ liver disease can present as a Sjogren's like syndrome
The coagulating factors are associated with what Vitamik?
If there are any liver problems, what to use besides Lidocaine?
If liver disease, Beta-lactam drugs can be used safely
Use ____ w/ caution
Avoid clindamysin, aminoglycosides, vancomycin, and macrolides,
Tetracycling, minocycline, doxy used at reduced dose
2 types of Hepatitis that need med consult even if not active:
*need to know bleeding concerns
In acute liver disease, only emergency care can be provided
GFR, may have hematuria/proteinuria:
anemia, secondary hyperparathyroidism
greater than 60
less than 15
Blood Urea Nitrogen (BUN) very important lab test for kidneys
*also Creatinine level/clearance
To achieve hemostasis Hematocrit levels should be greater than...
Wary of Nitrous and CKD pts
HTN - angiotensin receptor blocker
You can give Abx 2 hrs after procedure if Infective Endocarditis is missed
Ca channel blocker causes puffy gums
AUC guidelines are for ____ only