- medical consultations (NEVER A CLEARANCE, unless its for a specific procedure)
Medical complexity Classification MCS
- 0
- 1
- 2
Numbers - existence of disease
0 = no disease or condition
1 = controlled disease or condition
2 = uncontrolled disease or condition
Letter - Anticipated complication
A = no anticipated complication
B = minor anticipated complication (can be managed chairside)
C = major anticipated complication (not easily managed chairside, can be fatal)
DM- Dental Modification
DM-0 - no modifications needed
DM-1 - modifications needed before tx
DM-2 - modifications needed during tx
DM-3 - modifications needed after tx
How is the ANC (absolute neutrophil count) calculated?
Total of WBC times the % of neutrophils
* Less than 1,000-1,500 (ANC) is considered neutropenia and the patient is prone to infections
Most common cause of drug induced anaphylaxis
Penicillin
Initial reaction usually involves the skin but then second can be fatal with anaphylaxis
Clindamycin is the go to antibiotic for those allergic to penicillin medications.
What BP is considered hypertension?
anything over 140/90, below is called pre-hypertenson
The closet the diastolic gets to the sistolic, the most chance of getting a heart attack.
Sistolic (when the heart contracts)
Diastolic (when the heart relaxes)
For patients taking beta blockers (PROPANOLOL) or with stage II hypertension....
limit carpues of epi to 2
DIGOXIN (for heart failure) cannot have epi
DIfference between Antiplatelets and anticoagulants?
Antiplatelets (SECONDARY PREVENTION) (work with bleeding time, usually for minor heart complications) prevent the platelets from aggregating and sticking together, the most popular is Aspirin and Plavix.
Anticoagulants (PRIMARY PREVENTION) are used more for patients who have had major heart surgery or heart valve replacements to prevent thrombosis. Famous ones are Warfarin (coumadin) and Xerelto
DIfference between stable angina and unstable?
stable is associated with a heavy workload excersize
Which heart condition arrhythmia where patients are at risk for blood clots and heart attack, 20%
Atrial fibrillation
V-Fib is life threatening, cardiac arrest
for every cardio patient you MUST
MONITOR VITAL SIGNS
How long after an MI or heart attack can you see a patient for invasive dental procedures?
1 month, within the month it is a high risk
reversal for coumadin (warfarin)?
Vitamin K
* Some antibiotics and nutrition factors can affect coumadin
what are the standard antibiotic prophylaxis doses?
Diff between antibiotic coverage and antibiotic prophylaxis?
dont mix antibiotic treatments, they are done for diff reasons, prophylaxis is a MEGA DOSE.
Wait 10 days after antibiotic coverage is done to do dental treatment.
What happens in leukemic patients
Increased risk for bleeding with chemotherapy
Overgrowth of WBC, less space for platelets, less platelets means more bleeding!
3 examples that give coagulation complications
Vitamin K deficiency
Liver disease (produces all of the protein coagulation factors), portal hypertension
Anti-coag drugs or broad-spectrum antibiotics
How to manage a patient on anticoagulant medication before invasive procedure?
Do NOT discontinue medication (the risk is higher of a thrombotic event if done)
Manage with local hemostatic agents, atraumatic techniques
Avoid NSAIDS for pain
Patients taking coumadin
Need routine blood testing (INR) to determine appropriate dose and monitoring, can be dangerous if not properly and precisely controlled
Herbal medicine, veggie greens can be dangerous, as well as amoxicillin and doxycycline
DENTAL: AVOID NSAIDS and watch antibiotics, INR is needed for invasive procedures. For all NOACs (xerelto, eluquis etc...) consult medical team, but never stop the medication (risks are worse)
For ApTT (activted partial thromboplastin time), evaluates intrinsic blood factors
Normal values: 30-40
Spontaneous bleeding: >100
CANNOT TO DENTAL WORK: >80
* Hemophilia, liver disease, von willebrand, heparin, increases the aPTT.
for PT (Prothrombin time), measures Extrinsic factors
Coumadin INCREASES PT, THIS IS WHAT THE INR MEASURES
Normal: 11-13 sec
NO DENTAL CARE: >20 sec
INR must be within what time
Within 24 hours for invasive surgical procedures
within 72 hours for scaling and mand blocks
within 2 weeks if their INR is <3.0 within 2 weeks for routine dental care is fine
Platelet counts
>150k is NORMAL
< 50k NO ROUTINE DENTAL CARE
< 20K spontaneous bleeding
Bleeding control measures
Early in the day appointments
Fibrin adhesives and mouthwashes
What happens with Digoxin and epinephrine?
Arrythmias
Avoid intravascular injections
Stem cells that are obtained from another person, mos commonly a relative
Allogeneic
Has the risk of developing GVL (graft vs leukemia) or GVHD (Graft versus host disease)
Patients own stem cells that are collected and transplanted back
Autologous
Has less chance of rejection
The main oral complication that occurs in patients that receive stem cell treatment.
Mucositis, it peaks between post treatment days 6-12 and begins to resolve between 14-18 days.
Incidence of mucositis is 75-100
no NSAIDS used for treatment, only some topical and mouthwashes
First question to ask a person who has asthma is..
What activates the asthma?
Asthma is usually caused by an immunological reaction
Types of asthma attacks
Allergic (extrinsic) -seasonal variations, early childhood onset
Non-allergic (intrinsic)- idiopathic
Exercise induced- inhalation of cold air
Infectious - viral or bacterial
Atopic (allergen) and Non-atopic(non-allergen)
Main types of medications for asthma?
Bronchodilators: B and B2 agonists, epinephine and muscle relaxants
Anti-inflammatory agents: Steroids (singulair and flonase)
Some anticholinergic drugs
Main dental management in a patient with asthma?
Have the rescue inhaler nearby
Nitrous oxide can be used with mild-moderate asthma, but not severe
Avoid NSAIDS (especially Aspin) in sensitive patients, avoid macrolide antibiotics and clindamycin in pts who take theophyline.
Reduce enamel dust, avoid aerosols
What is the normal platelet count?
150-450k
50-150k treat ith local hemostatic agents
less than 50k cannot treat
less than 20k spontaneous bleeding
What is the normal WBC count
4-11 thousand
Main characteristic of anemia?
Reduction is oxygen-carrying capacity of the blood
independent risk factor for adverse cardiovascular outcomes
What organ determines the level of oxygenation and stimulates production and release of RBC?
Kidney, releases erythropoeitin
What type of anemia is formed because of the lack of b12 absorption and folic acid?
Pernicious anemia and folate deficiency
Hemolytic anemia is most commonly caused by....
Infection and aspirin
When do defer treatment of the anemic patient?
If the Hb is less than 10 and the patient is symptomatic
Also if there is history of CVD and the procedure will lose a lot of blood
Normal Hemoglobin ranges from 10-18
Oral manifestations of anemia?
- Pale mucosa
• Loss of papillae
• Angular cheliis and apththae
• Burning mouth, sore tongue
• Plummer-Vinson syndrome
characterized by a sore mouth, dysphagia and increased risk of oral or pharyngeal cancer.
Sickle cell anemia dental management?
Antibiotic prophylaxis for major surgical procedures, loading dose at the time of the procedure, usually for 7-10 days
Avoid aspirin and vasocontrictors, no care below 10 hemoglobin (nitrous needs more than 50% oxygen)
Anemia where the bone marrow cannot produce RBC and what causes?
Aplastic anemia
Causes: Mostly drugs, insectacides and viral infections
Does anemia cause bleeding?
Anemia does not cause bleeding but people with aplastic anemia are susceptible to infections.
Their function is to defend the body against infectious agents, primarily bacteria
Neutrophils.
The normal values are 1,500-8,000 /mm3
Leukocytosis vs leukopenia?
Leukocytosis is an elevated level of leukocytes in the blood, usually indicates infection or necrosis
Patients with Leukemia and Lymphoma are suceptable
Candida
Thrombocytopenia
Immunosuppression
Ulcers
Viral infections
and Advanced periodontal disease
Clinical signs for leukemia
ulcers, recurrent infections, gingival enlargement and bleeding, lymphadenopathy
In cancer patients, whats the time before when extractions could be done?
10-14 days before chemotherapy, PRE AND POST AB (consult with physician)
Some recommend extractions of pockets are more than 5mm
Less than how many WBC is antibiotic prophylaxis recommended?
2,000
The 4 conditions which require antibiotic prophylaxis
Previous endocarditis
Prosthetic heart valve
Congenital heart disease (unrepaired cyanotic heart defect, or congenital heart defect with prosthetic material or device during the first 6 months)
Cardiac transplant with hx cardiac valvulopathy
70yr old male takes nitroglycerin for angina, what dental management or modification needs to be done?
Have a nitroglycerin pill on the bracket table and check for expiration
Pt with history of CVA and is taking coumadin, what is the appropriate test to plan the extraction, above what value cannot be treated?
INR, cannot be treated over 3.5
INR measures the pT which is the only extrinsic pathway (factor 7)
aPTT is the intrinsic pathway (where we find factor 8, which is what is ruined in hemophilia)
** This is why hemophiliac patients need an aPTT test
What are the values of PT and aPTT?
aPTT- 30-40 sec is normal, more than 80 cannot be treated
PT- is 11-13 seconds, more than 20 cannot be treated, Patients taking coumadin have this affected directly, 24 hour INR is required.
Coumadin is affected by vitamin K and green vegetables.
2 contraindications of a patient wearing a pacemaker in dental management?
Electric pulp test and electrosurge
During the assessment of a patient diagnosed with arrhythmia we need to determine.
The type of arrhythmia may contradict dental treatment (severe)
Medications patient is taking (because of interactions with epinephrine and promote bleeding risk)
They can cause aFIB
What is the time recommended to wait before elective dental procedures after uncomplicated MI
4-6 weeks
What is the highest BP possible for tx?
180/100 but very important that there aren't any other organ damage of failure (heart and kidney)
Pt 52 yr old, never diagnosed with hypertension, wants to take out a tooth that is not hurting with high BP.
Cannot do it, it is an elective treatment. Instead pt should be referred to get treatment for high BP. 150/120
When BP numbers are too close together, it is a problem because the heart is not relaxing
Name 4 dental management recommendations for patients with Hypertension?
- Monitor vital signs, blood pressure
- Limit amount of vasoconstictor
- Avoid intravascular injections
- Control pain (excellent anesthesia), lessen stress and natural epinephrine
Sickle cell anemia needs...
Antibiotic prophylaxis recommended
DO NOT USE ASPRIN
NO BLANCHING WHEN USING ANESTHESIA
AVOID VASOCONSTRICTORS
Which type of anemia would you expect gingival bleeding?
Aplastic anemia, because the bone marrow is unable to produce adequate numbers of RBCs, white blood cells and platelets.
What conditions cause neutropenia?
Chemotherapy
Bone marrow disease
Steroids
Immunosuppression therapy
Lowest amount of ANC workable with HIV? any why?
500, because the quality of the neutrophils is good, opposed to low quality and quantity in other immunosuppressed conditions.
Based on the Viral load and cd4 count, what is considered when treating a HIV patient with antibiotic prophylaxis?
None, only ANC is considered (less than 500)
Viral load shows the progression of the virus, but does not have an impact on prognosis.
CD4 is the type of lymphocyte, but has no impact on AB prophylaxis
What is affected in von Willebrands disease and in Hemophilia and what is the management?
Deficiency in coagulation factors
Determine the severity by aPTT tests
Avoid aspirin and NSAIDs
Name 2 types of antithrombotic drugs and the labs needed to monitor the risk of bleeding?
Anticoagulants (warfarin, eliquis, xarelto) - the test is INR
Antiplatelets (aspirin and clopidrogel (plavix) - NO TEST FOR ANTIPLATELETS
aPTT tests for new anticoagulants can be done for extensive surgical procedures.
Medications to avoid in patients taking Coumadin?
Antibiotics (amox, doxycycline y metronizadole)
NSAIDS
Antifungales
Side effects of Calcium channel blocks are xerostomia and gingival hyperplasia?
FALSE
CCB do not give xerostomia
How with ACE inhibitors impact dental care?
Coughing
Orthostatic hypertension
Dry mouth
Which medications cause increase in BP?
Barbiturates
Cold and cough medicine
NSAIDS
Immunosuppressants
Which antidepressants can cause abnormal bleeding?
SSRI (paxil, prozac, zoloft, celexa)
Author
jesseabreu
ID
323980
Card Set
CMC First Exam
Description
care of medically complex patient - first competency