1. Acidosis endocrine consequences
    • hypoglycemia: hyperinsulemia->insulin resistance & reduced degradation
    • hypothyroidism: impaired peripheral converversion (T4 to T3)-> increased TSH
  2. electrolyte consequences of kidney function
    • hyperP, hypoCa ->osteodystrophy (metastatic Ca, osteopenia, osteoporosis)
    • eventually hyperNa,K (but may have compensatory periods of hypo) -> atherosclerosis, edema, heart failure, stroke
  3. Renal disease precautions
    • BP monitoring
    • bleeding (PLT)
    • anemia
    • infection
    • drug: avoid acetaminophen, ASA, NSAIDs, adjust doses for renal metabolism
    • uremic pts may have hypoalbuminemia
    • propoxyphene, codeine, meperidine, erythromycin, metronidazole
    • avoid CNS depressants (barbiturates, narcotics)
  4. CKD oral manifestations
    • xerostomia, taste alterations, parotiditis
    • oral candidiasis
    • uremic stomatitis, frost, breath
    • lichenoid
    • pyogenic granulomas
    • enamel hypoplasia
    • osseous changes (hyperPTH)
  5. uremic frost
    • uncommon derm manifestation of azotemia(uremia)
    • urea and other N-waste accumulate in sweat and crystallize after evaporation
  6. Which phase of syphilis has mucocutaneous lesions?
    • acute of primary and secondary syphilis
    • vs. bone, visceral, CV and CNS lesions of chronic
  7. syphillis diagnosis & tx
    • ID T. Pallidum, darkfield, serology
    • tx: PCN
    • 1: chancre
    • 2: rash
    • 3: quiet for years->gumma (granulomatous), neurosyph, CV (aneurysm), coinfect HIV
  8. STD ranking
    • 1. chlamydia
    • 2. Gonorrhea
    • 5. Syphilis
  9. gonorrhea diagnosis
    culture & nucleic acid amplification test (NAAT)
  10. oropharyngeal gonorrhea
    • phayngeal MC
    • stomatitis: non-specific
    • arthritis: TMJ
  11. __ of genital infections are caused by HSV _ and rest are due to HSV_
    • 85%: HSV-2
    • 15%: HSV-1
  12. HPV subtypes
    • high-risk uterine & anal cancer: 16, 18, 31,33,35,45
    • low risk benign oral: 6, 11
    • high risk oral: 2, 16, 18 (dysplastic & malignant)
  13. HPV vaccines
    • 6,11,16,18
    • cervarix only 16, 18
    • gardasil
    • recommended by 11-12 yrs old
  14. Wolff–Parkinson–White syndrome (WPW)
    • conduction disorder
    • pre-excitation syndrome
    • presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles.
    • Electrical signals travelling down this abnormal pathway (known as the bundle of Kent) may stimulate the ventricles to contract prematurely, resulting in a unique type of supraventricular tachycardia referred to as an atrioventricular reciprocating tachycardia.
  15. Metroprolol- Toporol XL
    • Beta (selective beta 1) blocker
    • heart beat slower and more complete
    • tx: mild WPW syndrome.
    • lowers the BP
    • increase the Ejection Fraction
    • lowers HR, BP and strain on heart
  16. levothyroxine:
    • synthetic thyroxine (T4)
    • Tx: Hypothyroidism. Also enlarged thyroid, thyroid ca.
    • Synthetic form of thyroxine.
    • T4 is converted to its active metabolite T3. T3 and T4 then bind to thyroid receptor proteins in the cell nucleus and exert metabolic effects through control of DNA transcription and protein synthesis; involved in normal metabolism, growth, and development; promotes gluconeogenesis, increases utilization and mobilization of glycogen stores, and stimulates protein synthesis, increases basal metabolic rate,
    • Chronic hypothyroidism predisposes patients to coronary artery disease
    • Long-term therapy can decrease bone mineral density
    • May decrease the levels/effects of sodium iodide; theophylline derivatives
    • Pregnancy risk factor: A (no adverse effects to the fetus)
    • Maternal hypothyroidism can be associated with adverse effects in the fetus, including premature birth and respiratory distress. Maternal hypothyroidism has also been associated with adverse pregnancy outcomes, including hypertension, anemia, and placental abruption. Presence of maternal thyroid antibodies may increase the risk of premature birth and miscarriage
    • Adverse effects can be decreased by maintaining maternal euthyroidism during pregnancy. Physiologic thyroid hormone concentrations should be maintained prior to and during pregnancy.
    • Levothyroxine is the drug of choice during pregnancy for hypothyroidism
    • Dose should be increased 30-50% by 4-6 weeks gestation
    • Monitor T4 and TSH levels during pregnancy and for at least 6 months postpartum
    • adverse effects:
    • angina, hypertension, headache, bone mineral density decreased
  17. furosemide: diuretic
    • Tx: Edema, htn
    • § Management of edema associated with heart failure and hepatic or renal disease, acute pulmonary edema; treatment of hypertension
    • § Inhibits reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule, interfering with the chloride-binding cotransport system, thus causing increased excretion of water, sodium, chloride, magnesium, and calcium
    • § Given in excessive amounts results in diuresis, resulting in fluid and electrolyte depletion
    • side effects: headaches, bullous pemphigoid, erythema multiofrme, rash, stevens-johnson syndrome, hypocalcemia, hypokalemia, metabolic alkalosis, anemia
    • § Pregnancy risk category: C
    • Maternal death, fetal toxicity and fetal loss in animal studies…no adequate studies in pregnant women. Crosses the placenta, increased fetal urine production, electrolyte disturbances
    • Use of diuretics during pregnancy is avoided due to risk of decreased placental perfusion, may increase birth weight
  18. albuteral inhaler prn (as needed):
    • bronchodilator
    • asthma, bronchitis
    • § Xerostomia
    • § Relaxes bronchial smooth muscle by B2-receptors with little effect on HR
    • § Avoid use with nonselective beta-blockers
    • § Albuterol may increase the levels/effects of: loop diuretics; sympathomimetics; thiazide diuretics
    • § Limit caffeine
    • § Pregnancy risk factor: C
    • § Crosses the placenta; tocolytic effects, fetal tachycardia, fetal hypoglycemia secondary to materal hyperglycemia with oral or intravenous routes reported. Available evidence suggests safe use as an inhalation during pregnancy, and albuterol is the preferred short-acting beta agonist for use in asthma
  19. Drug use in Pregnancy
    • § No schedule D drugs! (tetracycline, barbiturates, etc)
    • § Use caution with schedule C drugs
    • § In 3rd trimester avoid: ASA, Cox-2 inhibitors, ibuprofen, naproxen
    • § Use nitrous oxide only in 2nd trimester and less than 30 minutes
  20. Atorvastatin
    • (Antilipemic Agent, HMG-CoA Reductase Inhibitor)
    • Primarily for hypercholesterolemia and secondarily for clinically evident coronary heart disease. Contraindicated for active liver disease;
    • increases in HbA1c and fasting blood glucose have been reported
  21. Metformin
    • (Antidiabetic Agent, Biguanide):
    • management of type 2 diabetes mellitus. Contraindicated for renal disease or renal dysfunction (serum creatinine ≥1.5 mg/dL in males or ≥1.4 mg/dL in females) or abnormal creatinine clearance from any cause.
    • Patients with renal function below the limit of normal for their age should not receive therapy.
    • Dental information: Gastrointestinal: taste disorder
  22. Glipizide
    • (Antidiabetic Agent, Sulfonylurea)
    • Hypoglycemia more likely in elderly patients, and in patients with impaired renal or hepatic function; advanced age, and concomitant use of beta-blockers or other sympatholytic agents may impair the patient’s ability to recognize the signs and symptoms of hypoglycemia.
    • Stress-related states: It may be necessary to discontinue therapy and administer insulin if the patient is exposed to stress (fever, trauma, infection, surgery).
    • Secondary failure: Loss of efficacy may be observed following prolonged use as a result of the progression of type 2 diabetes mellitus which results in continued beta cell destruction. In patients who were previously responding to sulfonylurea therapy, consider additional factors which may be contributing to decreased efficacy (eg, inappropriate dose, nonadherence to diet and exercise regimen). If no contributing factors can be identified, consider discontinuing use of the sulfonylurea due to secondary failure of treatment. Additional antidiabetic therapy (eg, insulin) will be required.
    • Adverse Reactions:
    • Cardiovascular: Syncope (<3%)
    • Central nervous system: depression (<3%),
    • Renal: Blood urea nitrogen increased, creatinine increased
    • Dental information: Glipizide-dependent patients with diabetes (noninsulin dependent, type 2) should be appointed for dental treatment in morning in order to minimize chance of stress-induced hypoglycemia.
  23. Atenolol
    • (Antianginal Agent; Beta-Blocker, Beta-1 Selective): for hypertension, Angina pectoris, Postmyocardial infarction. Use caution with history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to repeated challenges. Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms. Use with caution in patients with a history of psychiatric illness; may cause or exacerbate CNS depression.
    • Adverse Reactions: Central nervous system: depression
    • Dental Information: Atenolol is a cardioselective beta-blocker. Local anesthetic with vasoconstrictor can be safely used in patients medicated with atenolol. Nonselective beta-blockers (ie, propranolol, nadolol) enhance the pressor response to epinephrine, resulting in hypertension and bradycardia; this has not been reported for atenolol. Many nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can reduce the hypotensive effect of beta-blockers after 3 or more weeks of therapy with the NSAID. Short-term NSAID use (ie, 3 days) requires no special precautions in patients taking beta-blockers.
  24. Hydrochlorothiazide
    • (Diuretic, Thiazide):
    • for Edema (diuresis) and Hypertension
    • • Ocular effects: May cause acute transient myopia and acute angle-closure glaucoma; discontinue therapy immediately in patients with acute decreases in visual acuity or ocular pain. Risk factors may include a history of sulfonamide or penicillin allergy.
    • Cardiovascular: Hypotension, orthostatic hypotension
    • Endocrine & metabolic: Hyperglycemia, hypokalemia, hyperuricemia
    • Hematologic: thrombocytopenia
    • Renal: Interstitial nephritis, renal dysfunction, renal failure
  25. Lisinopril
    • (Angiotensin-Converting Enzyme (ACE) Inhibitor):
    • for Heart failure, Hypertension, and Acute myocardial infarction
    • • Hyperkalemia especially with patients with renal dysfunction, diabetes mellitus and concomitant use of potassium-sparing diuretics.
    • • Hypotension/syncope: effects are most often observed in volume-depleted patients
    • • Renal function deterioration: May be associated with deterioration of renal function and/or increases in serum creatinine, particularly in patients with low renal blood flow (eg, renal artery stenosis, heart failure) whose glomerular filtration rate (GFR) is dependent on efferent arteriolar vasoconstriction by angiotensin II; deterioration may result in oliguria, acute renal failure, and progressive azotemia. Small increases in serum creatinine may occur following initiation; consider discontinuation only in patients with progressive and/or significant deterioration in renal function.
    • • Renal impairment: Use with caution in pre-existing renal insufficiency; dosage adjustment may be needed. Avoid rapid dosage escalation which may lead to further renal impairment.
    • Dental information: orthostatic effects
  26. Venlafaxine
    • (Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor) for Depression, Generalized anxiety disorder, Panic disorder, and Social anxiety disorder
    • Caution for • Bleeding risk: May impair platelet aggregation resulting in increased risk of bleeding events, particularly if used concomitantly with aspirin or NSAIDs due to ulcerogenic potential;
    • • Hypercholesterolemia
    • • Hypertension. May cause xerostomia, and may block salivary flow (parotid enlargement)
    • Dental information:
    • Local Anesthetic/Vasoconstrictor Precautions: Venlafaxine blocks norepinephrine reuptake within CNS synapses as part of its mechanisms. It has been suggested that vasoconstrictor be administered with caution and to monitor vital signs in dental patients taking antidepressants that affect norepinephrine in this way. Venlafaxine has been noted to produce a sustained increase in diastolic blood pressure and heart rate as a side effect.
    • Effects on Dental Treatment: Significant xerostomia (normal salivary flow resumes upon discontinuation); may contribute to oral discomfort, especially in the elderly; taste perversion.
    • Effects on Bleeding: May impair platelet aggregation resulting in increased risk of bleeding events, particularly if used concomitantly with aspirin, NSAIDs, warfarin, or other anticoagulants. Routine interruption of therapy for most dental procedures is not warranted. In medically complicated patients or extensive oral surgery, the decision to interrupt therapy must be based on the risk to benefit in an individual patient and a medical consult is suggested. If therapy is continued without interruption, the clinician should anticipate the potential for a prolonged bleeding time.
  27. Ticagrelor
    • (Antiplatelet Agent; Antiplatelet Agent, Cyclopentyltriazolopyrimidine):
    • Acute coronary syndrome.
    • Contraindications for moderate hepatic impairment; concomitant use of strong CYP3A4 inhibitors (eg, ketoconazole, clarithromycin, ritonavir, atazanavir, nefazodone)
    • • Bleeding disorders: Use with caution in patients with platelet disorders, bleeding disorders, and/or at increased risk for bleeding (eg, PUD, trauma, or surgery).
    • • Renal impairment: Use with caution in patients with renal impairment. Creatinine levels may rise during therapy (mechanism undetermined); monitor renal function.
    • Concurrent drug therapy issues:
    • • Aspirin/other NSAIDs: Maintenance doses of aspirin greater than 100 mg/day reduce the efficacy of ticagrelor and should be avoided.
    • • Discontinuation of therapy: Premature discontinuation of therapy may increase the risk of cardiac events (eg, stent thrombosis with subsequent fatal or nonfatal MI). Duration of therapy, in general, is determined by the type of stent placed (bare metal or drug eluting) and whether an ACS event was ongoing at the time of placement.
    • Patients taking ticagrelor may have shortness of breath.
    • Effects on Bleeding: In the case of dental surgery, there is no scientific evidence to support discontinuation of aspirin. The discontinuation of aspirin may place the patient at risk for a thrombotic event or other cardiovascular complication. In particular, aspirin should not be discontinued in patients with cardiac stents that have not completed their full course of dual antiplatelet therapy (eg, aspirin and clopidogrel [prasugrel or ticagrelor]); patient-specific situations need to be discussed with cardiologist. When feasible, postponement of dental surgery until the completion of dual antiplatelet therapy should be considered. Any modification of aspirin therapy should be discussed with the prescribing physician.
  28. Timolol eye drop
    • (Beta-Blocker, Nonselective; Ophthalmic Agent, Antiglaucoma) for Glaucoma: Ophthalmic:
    • • Diabetes: Use with caution in patients with diabetes mellitus; may potentiate hypoglycemia and/or mask signs and symptoms.
    • Concurrent drug therapy issues:
    • • Beta-blockers: Concomitant use with other topical beta-blockers should be avoided; monitor for increased effects (systemic or intraocular) with concomitant use of a systemic beta-blocker.
    • • Inhaled anesthetic agents: Use with caution in patients receiving inhaled anesthetic agents known to depress myocardial contractility.
    • Other warnings/precautions:
    • • Absorption: Systemic absorption of timolol and adverse effects may occur with ophthalmic use, including bradycardia and/or hypotension. Beta-blocker therapy should not be withdrawn abruptly in order to avoid acute tachycardia, hypertension, and/or ischemia. Patients undergoing major surgery should be gradually tapered off therapy prior to procedure.
    • • Appropriate use: Should not be used alone in angle-closure glaucoma (has no effect on pupillary constriction). Multidose vials have been associated with development of bacterial keratitis; avoid contamination.
  29. Mycophenolate mofetil:
    • Category: immunosuppressant agent. Cytostatic effect on B and T lymphocytes
    • Use: for transplant (usually renal, hepatic, or cardiac). Treatment of rejection in liver transplant pts unable to take tacrolimus,
    • EODT: Mouth ulceration, gingival hyperplasia, dry mouth, dysphagia, oral moniliasis, and stomatitis.
    • Adverse effects: Reduced platelet count. prodrug so may have impaired metabolism to active form and inactive form may have some undesired consequences. Multiple other adverse effects
  30. Prednisone:
    • Category: corticosteroid. Decrease inflammation by suppression of migration of PMN leukocytes.
    • Use: prevent inflammation and used for lung transplant .
    • Adverse effect: Must be metabolized by liver to active form. No major contraindications. increase blood sugar, immunosuppressant, mouth sores
  31. Tacrolimus:
    • Use: immunosuppressant agent due to lung transplant in 2010 and calcineurin inhibitor
    • EODT: stomatitis, oral moniliasis, dysphagia, and esophagitis
    • Adverse effects: Thrombocytopenia. Increased risk of developing renal insufficiency related to high while blood levels of tacrolimus
  32. Insulin Aspart (Novolog 5 U AM, 10 U AM, NPH 4 U PM):
    treat hyperglycemic state(may be to counteract the prednisone). Rapid acting insulin analog
  33. metoprolol:
    Anti-anginal, beta 1 blocker to control HTN. Metabolized by liver therefore should be given in lower doses to those with liver failure
  34. Azithromycin:
    Macrolide antibiotic (protein synthesis inhibitor) for prevention of IE
  35. Atovaquone:
    Anti-protozoal. Selectively inhibits parasite mitochondrial electron transport. Used to prevent pneumocysitis jirovecci pneumonia (PCP). May cause oral moniliasis (candidiasis).
  36. Voriconazole:
    • Anti-fungal to prevent pulmonary aspergillosis. Consult with physician prior to administering vasoconstrictor.
    • xerostomia
    • Monitor closely for toxicity to the liver and may cause visual changes
  37. Pantoprazole:
    Proton pump inhibitor to inhibit gastric acid secretion. May increase the risk of GI infections.
  38. Fenofibrate:
    Antilipemic agent, fibric acid. Reduces LDL, total cholesterol, triglycerides, and apolipoprotein B and increases HDL for those with primary hypercholesterolemia or mixed dyslipidemia.

    Dry mouth and tooth disorder may occur. May lead to thrombocytopenia. Adverse liver effects. Use is contraindicated in hepatic impairment
  39. Alendronate:
    • Bisphosphonate derivative to prevent osteoporosis which may be provoked by prednisone/ corticosteroid use.
    • May cause osteonecrosis of the jaw associated with local infection, tooth extraction, or delayed healing. Adverse effects are mostly GI related and may lead to hypocalcemia or hyperphosphatemia. Inhibits bone resorption via actions on osteoclasts or on osteoclast precursors, decrease bone resorption leading to an increase in bone mineral density.
  40. Albuterol inhaler:
    • Beta 2 adrenergic agonist
    • bronchodilator (relaxes bronchial smooth muscle by action on B2 receptors with little effect on HR) to prevent bronchospasm.
    • xerostomia.
  41. Baby ASA:
    • Antiplatelet agent.
    • Affect hemostasis and leads to prolonged bleeding
  42. Magnesium:
    Prevent nutritional deficiency. May lead to diarrhea. watch levels with Kidney failure
  43. Fish oil
    Lower risk of coronary artery disease and decreasing serum triglycerides.
  44. Calcium/ vitamin D
    Treat hypocalcemia. Metabolized in liver and kidney, could be affected by cirrhosis.
  45. hepatic disease
    • fatigue
    • pruritus-impaired bile secretion
    • poor appetiti & weight loss
    • abdominal pain (esp when eating)
    • jaundice
    • altered taste & smell (Zn Mg vit A deficiency
    • dyspnea portal HTN & ascites
    • GI bleeding (portal HTN
    • bone pain: reduced D absorption
  46. hepatic disease signs
    • scleral icterus(yellow skin, muc mem)
    • spider angiomas
    • xanthelasmas
    • parotid enlargement
    • distented neck veins
    • distended abdomen w/ bulging flanks
    • bruises
  47. ALT, AST
    • elevated in hepatocellular diseases
    • injured liver cells spill into blood stream
  48. ALP or ALK
    • alkaline phosphatase
    • increased in hepatic disease from bile duct obstruction and excessive osseous activity
  49. GGT
    • gamma-gluatmyl transferase
    • elevated in liver disease & bile duct obstruction, but not in bone disease

    isolated elevation w/o other enzymes-> alcoholic liver disease
  50. drugs that raise liver enzymes
    • pain relief
    • anti seizure: phenytoin, valproic
    • antibiotics: tetracyclines
    • antifungals
    • statins, niacin
    • CV drugs
    • antidepressants: tricyclics
    • * most return to normal after cessation(weeks/months)
  51. how is liver clearance tested
    • serum bilirubin (includes direct(conjugated) & indirect (unconjugated)
    • hyperbilirubinemis > 1mg/dL
    • jaundice: plama of 2.0-2.5 mg/dL
  52. how is hepatic sythetic function tested
    • coag proteins (PT/PTT)
    • albumin, globulin (ratio)
  53. in liver disease serum albumin & globulin levers are ____
    • reduced
    • albumin exclusively liver produced
    • hepatoglobulins (alpha beta) liver
    • lipoprotiens a2 and B globulins not affected
    • gamma-globulins and iG increased if immune mediated
  54. A/G ratio
    ratio lower in disease normal since numerator(albumin) drop is proportionally more
  55. which hepatitis is DNA virus?
  56. which hepatitis virii are STD?
    B,D (D needs B (carriers ususally drug users)
  57. Which hepatitis is chronic?
    • B , C
    • drugs, (P450, acetominophen)
    • autoimmune (ANA, SMA, LKM1)
    • alcohol(steatohepatitis->fatty liver)
    • metabolic (hemochromatosis, alpha1 antitrypsine def, wilson's)
    • infiltrative: granulomatous, lymphoma, amyoidosis
  58. Wilson's disease
    • copper
    • hepatocytes
    • CNS
    • kidneys
    • endocrine
    • tx: chelation (Zn acetate)
  59. alpha1antitrypsine deficiency
    • AR
    • deficient glycoprotein that inhibits serine proteases capable of destroying connective tissue
    • ephysema & liver failure
    • no tx
  60. hemochromatosis
    • iron deposition-> liver, heart pancreas, skin & joints
    • tx: phlebotomy
  61. cholangitis
    biliary tract infection
  62. liver disease questions
    • cause
    • HTN?
    • hx of hematemisis: venous collaterals between portal & systemic (varices) & variceal hemorrhage in fundus & esohpagous -> anemia
    • weight loss?
    • spider angiomas: impaired clotting factors II, VII, IX, X)
    • thrombocytopenia
    • drug metabolism/detoxification issues
  63. hematemisis
    • venous collaterals between portal & systemic (varices)
    • variceal hemorrhage in fundus & esohpagous -> anemia
  64. liver comorbid conditions
    • anemia
    • R heart failure: portal HTN
    • pancreatic (DM)
    • obesity (fatty liver)
    • ascites
  65. ascites
    fluid in peritoneal cavity-> renal insufficiency & failure
  66. liver disease implications
    • know bloodborne infections
    • comorbid conditions(CV, Renal, neuro, immune, hemapoetic)
    • know degree of dysfunciton (cogulation, serum levels, hematological)
  67. hematemesis
    • upper GI
    • PUD, varices, malignancy
  68. melena
    black tarry stool (upper GI bleeding)
  69. hematochezia
    • dark red stool
    • lower GI
    • hemorrhoids, diverticulosis, colon CA
  70. chronic GI bleed test
    • hemoccult-positive stool (may be GI malignancy)
    • Fe deficiency anemia
  71. chronic diarrhea could indicate ____
    • IBD (inflammatory bowel disease)
    • rarely motility problem
  72. What BP do you defer dental care?
    >=180/110 or lower if symptomatic
  73. HTN Epi use
    • OK with controlled
    • 2-3 carpules (.036-.054mg) Stage 1 (140-159 or 90-99)
    • Avoid Stage 2 (>=160 or >=100)
    • Never use epi cords
  74. Why is NO use a concern for HTN?
    hypoxia -> reflex HTN
  75. What does CRP measure?
    • elevated = inflammation
    • heart disease risk factor
  76. What ages is heart disease leading cause of death?
    • >40 men
    • > 65 women
  77. Prinzmetal angina
    • variant angina or angina inversa
    • cyclic angina (cardiac chest pain) at rest
    • caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than directly by atherosclerosis (buildup of fatty plaque and hardening of the arteries).
    • It occurs more in younger women.
    • early AM
  78. unstable angina
    long, at rest
  79. MI blood test indicators
    • cardiac troponin
    • CK-MB (creatine kinase)
  80. No elective care for ___ post MI
    6 months & ensure normal cardiac function before routine care
  81. IHD management supplies
    • nitroglycerine
    • IV line
    • ECG monitor
    • pulse ox
    • *know cardiac status and monitor
  82. prophy AB should be considered ____ post CABG
    6 months
  83. heart failure edema
    • right heart: generalized fluid
    • left heart: pulmonary congestion, leads to R sided failure
  84. heart failure tx goals
    • decrease preload, afterload (diuretics, ACEi, Bblock)
    • improve contractility(cardiac glycosides)

    correct complications: anemia, arrhythmias, heart block

    diet: Na intake
  85. L heart failure causes
    ischemic, valvular, cardiomyopathies
  86. R sided heart failure causes
    • L heart failure
    • obstructive lung, pulmonary HTN or emboli
  87. HF dental implications
    • OK for compensated
    • pulmonary edema: can't lay down
    • EPI judicious
    • stress reduction
    • med side fx and interactions
  88. normal ejection fraction
  89. what drugs are typically used for arrhthmia pts preop?
    • benzodiazepine
  90. congenital heart defect concerns
    • corrected?
    • uncorrected->cyanotic?
    • avoid IV injection of anesthesia, vasoconstrictor
  91. when do congenital heart defects need prophy AB?
    6 months within correction or residual shunting exists
  92. rheumatic fever questions
    • which valve?
    • mitral stenosis (tight)-> inc L atrial pressure, reduced CO
    • mitral regurgitation (leaky)-> L atrial enlargement, pulmonary edema, L heart failure
  93. valve replacement precautions
    • AB prophy
    • anticoag if mechanical NOT necessary bioprosth
  94. murmur concerns
    • no AB prophy
    • organic = valve problem
  95. IE concerns
    • hx: time, course, cause
    • acute: marked toxicity, several weeks, S. aureus
    • subacute: months, modest, metastatic, S. Viridians, enterococci
  96. IE prophy guidelines
    • + hx of IE
    • prosthetic valves
    • CHD: unrepaired cyanotic, within 6 months of repair, residual defects
    • transplant w/valvulopathy
  97. IE signs
    • petichiae
    • splinter
    • janeway
    • oslers
    • roth spots (retina)
    • + diagnosis DUKE criteria (+ culture or trans esoph echo of vegitations)
  98. renal failure GFR
    • <15mL/min
    • req hemodialysis
  99. best predictor of atherosclerotic heart disease
    Total cholesterol:HDL  < 3.5
  100. endothelial vasodiators
    • EDRF, NO, prostacyclin
    • NO anti-inflammatory too-> protective ischemia
  101. Basic natriuretic peptide (BNP)
    • secreted by the ventricles
    • response to excessive stretching of heart muscle cells (cardiomyocytes).
    • INCREASES with heart failure
  102. First trimester:
    • fatigue, potential for hypotension & syncope
    • Avoid Elective
  103. Second trimester:
    • very few symptoms, continued hypotension
    • routine care
    • NO <30 mins OK
  104. Third trimester:
    • increased fatigue, mild depression, slight
    • hypertension
    • avoid hypotention, lengthy appts
    • avoid: ASA, Cox-2
    • inhibitors, ibuprofen, naproxen
  105. Supine hypotensive syndrome:
    • impaired venous return in late pregnancy
    • o Drop in BP, bradycardia, sweating, nausea, weakness, hunger for air,
    • fainting because of drop in CO.
    • o Turning pt to the left side should reverse the process
  106. Fetus is most susceptible to damage in ___ trimester during major organ development
  107. pregnancy management
    • Establish trimester and health status - is
    • mother in prenatal care?
    • o Plaque control, good OH & home care,
    • chlorohexidine rinses when indicated, diet
    • counseling
    • • Most common oral manifestation are
    • pregnancy gingivitis & pyogenic
    • granulomas
    • o Prenatal fluoride (2.2 mg tablet of systemic
    • & topical F-)
    • Avoid elective dental care in 1st trimester
    • o Perform routine care in 2nd trimester -
    • eliminate active disease and eliminate
    • potential problems that may occur later in
    • pregnancy
    • o May still treat in the beginning of third
    • trimester - attention to pt's positioning,
    • avoid hypotension, avoid lengthy appts
    • o Usejudgment in obtaining radiographs
    • • Use selected fields, adequate shielding,
    • ultra speed films, etc
    • o Ideally no drugs to be administered during
    • 1st trimester
    • NO category D drugs!!!
    • category C=caution
  108. breast feeding
    • take medication after
    • breast feeding and avoid nursing for
    • rv 4 hrs
    • o Generally must avoid:
    • • Lithium, antineoplastic drugs,
    • radioactive pharmaceuticals
  109. C-peptide and insulin
    • co-secreted in equimolar amounts into the portal circulation
    • o In type 1 diabetes, autoimmune destruction of the beta cells results in deficiency of both insulin and C-peptide
    • o In type 2, insulin production drops but C-peptide levels remain relatively normal
  110. Grave's Disease
    • MCC hyperthyroidism
    • TSH-R Ab [stim]
    • Exophthalmos (ocular proptosls)- may be bilateral or unilateral, is independent of thyroid hormone levels
    • o Classified based on severity to involve spasm of upper lid (as in thyrotoxicosis), infiltration of inflammatory cells into orbital tissues & muscles, irritation of conjunctiva and optic nerve compression
    • Pretibial myxedema - infrequent, extreme thickening of skin
  111. Hashimoto's Thyroiditis
    • Chronic Lymphocytic Thyroiditis
    • • An autoimmune raised circulating levels of thyroid
    • peroxidase antibody
    • o About a quarter of the people with this condition also have mitral valve proplapse - the most common
    • autoimmune type
    • o Replacement of T4 hormone (thyroxine) is
    • the cornerstone of therapy
  112. Restrictive Diseases
    • Alteration in lung parenchyma
    • o Collagen-vascular diseases - scleroderma, SLE, ankylosing spondylitis
    • o Medications - dilantin, bleomycin, methotrexate, radiation
    • o Inorganic or organic dust exposure - silicosis, pneumonitis
    • o Idiopathic pulmonary fibrosis (IPF)
    • o Sarcoidosis
    • • Pleural diseases - fluid accumulation in pleural space
    • o Seen in pneumonia, pulmonary embolism, malignancies,
    • heart failure
    • • A defect in the chest wall or the neuromuscular
    • apparatus that leads to hypoventilation
  113. respiratory Dental Issues
    • Patient positioning (avoid orthopnea)
    • No LA precaution except avoid bilateral blocks
    • Avoid rubber dam in severe dyspnea
    • o May require low flow of oxygen; avoid N20j02
    • • Use pulse oxymetry
    • o Avoid CNS depressants (narcotics & barbiturates)
    • o Avoid drying agents (anticholinergics,
    • antihistamines)
    • o Consider coexisting cardiovascular conditions
    • o May need corticosteroid supplementation
    • o Consider all drug interactions
  114. pulmonary embolism tests
    • D-dimer test, spiral CT scanning preferred over ventilation - perfusion scans for Dx
    • Tx: anticoag ulation & fibrinolytic agents
  115. pulmonary HTN
    • >=25mm Hg at rest >=35 excercise
    • ->right ventricular overload and failure, increase coag risk
  116. pneumonia vaccinations
    • pneumococcal boost every 5 yrs
    • influenza: annual
    • H. influenzae: infant or immunocompromised
  117. Progressive Systemic Sclerosis (case 4 possibly)
    • A multisystem connective tissue disorder
    • Unknown etiology
    • • Characterized by progressive interstitial fibrosis with atrophy and sclerosis of many organ
    • systems
    • o Skin, internal organs and the walls of blood
    • vessels
    • o Pulmonary scleroderma
    • • Diffuse interstitial infiltrates, sclerosis & progressive volume loss
    • • CXR: fibrocystic spaces (Honeycomb) mostly at lung bases
  118. Pneumonia
    • Inflammation of the lower respiratory
    • air spaces (alveoli), some causes:
    • 1. Streptococcus pneumonia (recent penicillin
    • resistance, vaccine available)
    • 2. Influenza viruses (during epidemics, vaccine available)
    • 3. Atypical pneumonia due to Severe Acute
    • Respiratory Syndrome (SARS) and pneumonia caused by CA-MRSA
    • o Predisposing conditions: smoking, hospitalization, immunocompromised state, aspiration, periodontal disease
    • o Symptoms
    • • Fever
    • • Cough
    • • Sputum production
    • • Various degrees of respiratory failure
    • o Signs
    • • Decreased breath sounds
    • • Rales, rhonchi, dullness to percussion
    • • May see a toxic appearance, fever,
    • pleu ritic chest pain, rusty colored
    • sputum
    • o Elderly: loss of appetite, failure to thrive,
    • confusion & dehydration
    • History and physical examination
    • • Predict microbial origin
    • • Determine the need for hospitalization (e.g.,
    • severe tachypnea or signs of respiratory
    • failure)
    • o Chest x-ray
    • o Sputum and blood cultures
    • o Treatment is with appropriate antibiotics
    • o Endotracheal intubation and mechanical
    • ventilation wi severe hypoxemia
  119. Ulcerative colitis
    • • Increased incidence of colon cancer; may be associated
    • with hypercoagulable state, arthritis, skin lesions
    • (erythema nodosum), kidney stones
    • • Dx:
    • • History (diarrhea wi blood in stool, abdominal pain,
    • bleeding, weight loss, fever) or any complications
    • (massive hemorrhage, colonic stricture, polyp,
    • adenocarcinoma, perforation)
    • • Barium enema, endoscopy and biopsy
    • • Tx: anti-inflammatory and immunosuppressive drugs, Sx
  120. Crohn's disease
    • • Granulomatous inflammation wI unknown etiology,
    • involves any part of the GI
    • • Ox:
    • • History (R lower quadrant abdominal pain, diarrhea,
    • weight loss, bleeding is uncommon), any
    • complications (intestinal obstruction, anal canal
    • fistulas, malabsorption, extra intestinal similar to UC)
    • • Radiography, endoscopy, biopsy
    • • Tx: same as UC plus hyperalimentation wI
    • significant absorptive problems
  121. IBD and dentistry
    • oral clinical aspects
    • ~Aphthous ulcers w/ IBD in general
    • ~uc: pyostomatitis vegetans
    • ~Crohn's: papulonodular eruptions, oral signs & symptoms w/ malabsorption
    • ~Medication side effects mostly w/ immunosuppressive drugs
    • ~Malabsorption may cause oral mucosal
    • abnormalities, burning & pain
  122. Diverticulosis
    • herniations of mucosa and submucosa through colonic muscle at sites where arteries penetrate
    • • Most common in colon usually on left side
    • ~ May be related to low- fiber diet and usually asymptomatic
    • ~ Complications include:
    • • Diverticulitis: when diverticula become impacted wI a mass inflammation, erosion and perforation may occur
    • • Bleeding
    • ~ Symptoms and signs seen w/ diverticulitis
    • • Left lower quadrant pain, diarrhea or constipation, bleeding
    • ~ Diagnosis is by barium enema, CT scan, ultrasound, and endoscopy
    • ~ Treatment is either medical (antibiotics and IV fluids) and surgical (for complications)
  123. diabetes test
    • FPG ~ 126 mg/dL x 2
    • 2-hr ~ 200 mg/dL
    • HbA1c of> 6.5% x 2
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