It is the type of transplant done with one self
- Autograft, considered an Autologous graft
- - Bone, stem cells
It is the type of transplant between genetically identical individuals (such as monozygotic twins)
Isograft, considered a synergeneic graft.
It is the type of transplant from a genetically different individual of the same species...
Allograft, considered an Allogeneic graft
A transplant between two different species.
- Xenograft, considered Xenogenic
- - Bovine grafts
When it comes to the types of rejection of transplantation, this one can occur from days to weeks and it involves the primary activation of the T-cell response.
When it comes to the types of rejection of transplantation, this one can occur from months to years after transplantation, probably occurs by continued cell medicated toxicity and under unclear causes...
- Chronic rejection
- - This one creates a big problem because sometimes the causes are unclear
When it comes to the types of rejection of transplantation, this one occurs minutes to hours after transplantation and is caused by performed anti-donor antibodies activation compliment.
Main complications of transplants...
- Immunosupressive drugs can make host suceptable to infection and cause hepatoxicity and nephotoxicity (can also make prone to malignancies).
- GVHD can cause a whole host of issues and some even affecting the GI tract, mucosal ulcerations make for opportunistic infections.
Dental management of transplant patient...
- - Should be coordinated with physician (medical consultation)
- - Prior to transplant, acute oral infections must be managed to prevent complications
- - Elective dental treatment can be done after transplantation
- ** Always assess comorbidities, medicatons and labs, patients with end-organ damage
Prior to transplant, the most important dental considerations...
- Eliminate active dental disease and infection (extractions of non-restorable teeth, oral infections and prevention)
- - Immunosuppresive drugs after transplant will debilitate the patients ability to fight infections.
In an immediate post transplantation state or in post-transplantation chronic rejection state, what dental treatment can be done?
No elective dental treatment and only emergency treatment, as non-invasive as possible.
In a stable post-transplant period, how is the dental patient managed?
- Check medications and side-effects (patients take a lot of immunosuppresants and steriods)
- Consideraton for AB prophylaxis
- Specific management needs based on the ogran type that was transplanted.
What is the main oral side effect noticed in patients taking cyclosporine?
- Gingival hyperplasia
- - Dilantin (for sezures) can cause gingival hyperplasia as well
- Cellcept can cause thrombocytopenia
- (CCB also cause gingival hyperplasia but it is associated more with plaque accumulation)
- Prednisone can cause opportunistic infections (it is a steroid) that is suppressing the immune system
What are the normal blood A1C and Glucose ranges?
- A1C (Glycinated hemoglobin):
- >5.7% Normal
- 5.7-6.5% Prediabetic
- <6.5% Diabetic
- Fasting Blood Glucose
- <126 Diabetic
- >100-110 is normal
Questions when a patient tells you they are diabetic?
- When were you diagnosed? Patients who have been diabetic for many years have a risk of target, end-organ disease
- How is the Diabetes being treated? Diet, exercise
- How often is the blood sugar tested?
- When was the last time you ate?
Symptoms of hypoglycemia
- Blood sugar under 70
- Shakyness, sweating, irritability, nausea, headache, weakness, seizure unconsciousness
Risks with uncontrolled diabetics in dentistry?
- Poor wound healing
- Risk of infections
- Hypoglycemic events
- DIABETICS HAVE NO ISSUES WITH BLEEDING
Local anesthesia Management of diabetic patients with target end organ failure? kidney failure/dialysis or uncontrolled cardiac issues...
Limit epi to 2 carpules or less
How do sulfonylureas work and what do they have a high risk of giving the patient?
- Stimulate the beta-cells to create more insulin, this can cause a hypoglycemic event (in the case where the patient has not taken in enough calories).
- Cannot work for type1 diabetes (because there are no beta cells in that type). These types of medications aren't used as much.
- *Must keep glucose source available
Biguanides (for diabetes) function is which way, and do they cause hypoglycemic events? Main side effect?
- Biguanides (like, Glucophage), increase the insulin sensitivity in muscles and decrease production of glucose in the liver
- This does NOT increase hypoglycemic events because there is not more glucose being produced in these medications.
- Major side effect is taste disorder
DPP-4 inhibitors in diabetics work with this function, and what is a major type?
- These work to reduce glucagon and improve the A1C (without causing glycemia)
- Januvia is a famous one now
SGL2- inhibitors (for diabetes), function and which are the major types?
- Inhibit the re-absorption of glucose in the kidney.
- Invokana is a famous one with side effects like: dizziness, syncope, orthostatic hypotension, bone fracture and ketoacidosis
As far as injectables for diabetes, the Incretin Mimmetics function in which way...
- Increase insulin secretion
- Decrease liver glucose production
- Decrease risk of hypoglycemic (unless combined with sulfonylureas
- (Usually injected with a Pen)
- Insulin is the other injectable, comes in short, intermediate, rapid onsets etc...
In a patient whos A1C is above 9 and Blood glucose is above 200 what risks are there and what is done to prevent those? Especially if they have target end organ disease.
- Risk of infection and poor wound healing post operatively
- During the treatment there could be a risk of a hypoglycemic event
- We will treat with AB prophylaxis.
To avoid hypoglycemic events schedule surgical, anxious or history of hypoglycemia patients...
- Mid morning appointments
- Have a Glucose source nearby
Chronic kidney disease is after what amount of time?
CKD (Chronic kidney disease) is classified based on .....
- GFR, glomerular-filtration rate
- less than 90 is stage 1 (30-60moderate)
- less than 15is stage 5 (kidney failure-end stage renal disease), present with many comorbid diseases (anemia, HTM, DM, HPT)
Lab tests to measure kidney function and failure include...
- Creatine clearance
- Glomerular filtration rate
- Blood urea nitrogen
Conditions that destroy nephrons?
- HTN & DM
- Polycystic kidney disease
- Systemic lupus
- Aids nephropathy
- Hereditary factors
Oral manifestations in kidney disease (in xrays)
Radiolucencies in mandible (not associated with tooth pathology)
How are stage one and two kidney disease (conservative approach) treated compared to advanced renal disease?
- Conservative : electrolyte balance, control HTN (with medication), control diabetes (A1C less than 7), modify diet (statins)
- Advanced approach: Dialysis, kidney transplant
What are the types of dialysis?
- Hemodialysis - cannulization for access, catheters in neck, heparin is administered to prevent clotting
- Peritoneal- hypertonic solution is inserted to the peritoneal cavity
Oral Manifestations to consider with kidney disease?
- Abnormal bleeding
- Hypertension (may be taking medications so watch for orthostatic Hypotension)
- Drug intolerance
- Skeletal abnormalities (in mandible)
- Nutritional deficiencies (anemias)
How to manage medications in kidney disease?
- Analgesics: Avoid nephrotic drugs if GFR is under 60, avoid long term NSAIDS (aspirin), avoid narcotics
- Antibiotics: consider hospitalization for major infections or procedures, if >60 GFR dosage adjustment for (amox, tetra and ceph), clindamycin needs NO adjustment
- Anesthesia: no adjustment necessary, just consider co-morbidities
- *acetaminophen is safer than NSAIDS when GFR below 60, avoid drugs secreted and metabolized by kidney
The risk of bleeding in kidney disease is due to...
- Platelet dysfunction ( or defective production)
- Decreased production of von Willebrand factor (patients with uremia)
Considerations for a patient on hemodialysis?
- Dental treatment must not be done on a day of dialysis
- Blood pressure monitoring on the arm without the shunt
- AB prophylaxis is NOT required due to AHA, but consider co-morbidities and immune system.
How is uremic stomatitis presented orally?
- Red burning mucosa
- Urine- smelling breath
Seizures can be of which types?
- 1. Epileptic (Idiopathic epilepsy or secondary epilepsy)
- 2. Non-epileptic (can be caused by another medical condition or state)
Partial seizures (part of the brain) can be...
- Simple: few seconds, conscious, hallucinations, numbness tingling
- Complex: loss of consciousness from 30sec-2min, nausea/vomiting, dilated pupils, hallucinations, mental confusion
Generalized seizures, involve the whole brain, can be...
- Tonic/clonic (grand-mal) seizures: loss of consciousness, contractions, urinary incontinence, tongue and cheek biting, lasts less than 90 seconds
- Absence: common during childhood, 10-30sec loss of consciousness, no memory of seizure, no convulsions
- Seizures that last a long time, or many seizures that occur together without a resting time
- 60-80% of patients achieve no seizures after 5 years treatment, but poor complicance
Common side effects of anti-convulsant medications?
- Carbamapazine: Delayed healing and xerostomia, infection, osteoporosis
- Dilantin: Osteoporosis, anemia, infection, gingival overgrowth, delayed healing, leukopenia
- Valproic acid: Bleeding, delayed healing, neutropenia, interaction with aspirin and NSAIDS
- Lamotrigine: Ataxia (loss of movement control)
Dental Considerations for working with seizure patient?... Before and during
- Before: Using mouth props, Keep in supine position
- During: Clear area, turn patient to side, keep fingers outside mouth of patient
- ** Call 911 if seizure lasts more than 5 minutes, monitor vital signs and examine for traumatic injuries
Questions for a seizure patient before appointment?
- Have you taken your medications?
- Did you take them today?
- When was your most recent seizure?
- How are you feeling?
What kind of dental materials are preferred for seizure patients?
- Use metal when possible, reinforced dentures
- Use fixed prosthesis over removable
- Use composite over amalgams for restorations
- Use rubber damn for restorations.
In peptic ulcer disease, how does it present and what is the usual cause?
- Mostly presents as a focal break in the stomach mucosa
- Usually caused by Helicobacter Pylori
- Second most common cause was NSAIDS (especially asprin) in long term therapy. Now they are coated to counter the acid.
- Also alcohol, smoking and stress
For management of GERD, which 2 common medications are used
- Antiacids (tums) counter the acid
- Histamine H2 receptor antagonists (prilosec, nexium)
- Dry mouth and taste perversion are seen
What is the common medication management for peptic ulcers?
Combination therapy 10-14 days, antibiotics (clari, metro, amox), proton pump inhibitor and a antiacid
Dental management for peptic ulcers
- Avoid NSAIDS, check antibiotics (if under the combined therapy treatment)
- Chair position for patient comfort
Two different inflammatory bowel disease, whats the treatment
- Ulcerative colitis (only in large intestine
- Chrons disease (who GI tract)
- No cure, management with: Antidiarreal, corticosteroids, surgery, antinflammatory, Immunosuppresive agents (chrons)
- * Avoid clindamycin, supplement steroids (if they are on them), avoid NSAIDS when possible
Common vitamin b12 deficiency oral manifestation
What does MS attack? UNKNOWN ETIOLOGY
- CNS, Optic nerve and spinal cord
- Progressive Demyelination of nervous pathways (autoimmune reaction)
- IS FATAL and damage comes from the scarring left after destruction
What are the oralfacial manifestations of MS?
- Facial numbness or spasms
- Electric shock spine
- Trigeminal neuralgia
- *Depression is seem in over 50%
Long term steroid use side effects?
- Raised BP
- Peptic ulcer
- Adrenal suppresion
- Immuno suppresion (infections)
The most common form of dementia and what types of medications are used to treat it?
- Alzheimers disease
- Acetylcholinesterase inhibitors
- Common: Levodopa (for dopamine deficiency), and COMT (limit to 2 carpules of epi)
Autoimmune disorder that presents with acetylcholine attack on a muscle group.
- Mysthenia gravis (drooping eyes, limbs, weak)
- Corticosteroids used to treat (IF DOING AN EXTRACTION, YOU HAVE TO SUPPLEMENT TO COUNTER THE STRESS)
What is the dental management prior to chemotherapy?
- exam and prophylaxis (rid infections)
- consult and request lab values in hematalogic cancers
- Check for immunosuppression (infection) and thrombocytopenia (bleeding)
- Eliminate sources of trauma because of xerostomia and mucositis
For radiation thats going to hit teeth, what is the treatment for those teeth prior?
- Maxillary 10-14 days prior
- Mandibular (absorbs more radiation) 14-21 days prior
- TO ALLOW FOR HEALING
Complications of head and neck radiation?
- Early: Mucositis, taste alteration, xerostomia and secondary infections
- Late: radiation caries, Limited mouth opening (trismus), osteoradionecrosis, pain and necrosis
Inflammatory disease where the synovial tissues proliferate uncontrollably and cause fluid accumulation and erosive destruction of bone, cartilage, tendons etc...
- Rheumatoid arthritis (onset is earlier age than osteoarthritis)
- Causes severe pain, swelling and stiffness
- Association with periodontal disease is being studied (because of constant inflammation), and the possibility of some viruses triggering RA
- Genetic + environmental. Skin subcutaneous nodules can be seen 25% of cases, splenomegaly (anemia, thrombocytopenia, neutropenia). Pericardial fluid
Treatment for RA (similar to Psoriatic arthritis)
- Early aggressive treatment, to stop inflammation and put disease in remission
- Long term NSAIDS, COX-2 inhibitors to prevent stomach Celecoxib
- DMARDS, Methotrexate (careful with NSAIDS and stomatitis). Disease modifying drugs
- Bouchard's nodes (swans neck hands) can sometimes require joint replacement surgery (Heberden's nodes are seen in osteoarthritis and are seen at the first joint of the finger)
Side affects of corticosteroids
- Adrenal Suppression
Inflammatory arthritis characteristic of temporal arteritis, Jaw pain, vision issues and more common in females
- Giant cell Arteritis, usually seen in over 70years
- Masticatory pain limited to one side
Autoimmune disease with multiple presentations that attacks healthy, skin, joints, brain and other organs with fever, rash, pericarditis, anemia, etc...
- Systemic lupus erythematosus (affects all organs)
- Discoid lupus erythematosus (primarily affects the skin)
- Chest pain, sores in mouth, rash, sensitivity to sunlight, swollen lymph nodes, fingers change colors, can cough blood
- Treatment is similar to all autoimmune, cellcept (depletes immune system)
- Management needs to consider AB for immunosuppresion, steroid supplementation and bleeding PT(INR) and PTT
Chronic pain for more than 3 months when more than 4kg of pressure is applied, present on all 4 quadrants of the body.
- Treatment is antidepressive drugs (dry mouth and bruxism)
- Careful with chair position
Autoimmune disease that affects mainly salivary and lacrimal glands.
- Sjogrens syndrome, can present with angular chelitis, enlarged salivary glands, etc.
- Can be treated with Methotrexate (and other autoimmune drugs) be careful of the side effects.
Scleroderma presents with
- Calcified deposits in skin, tightening of skin and esophagus, cannot open mouth, problems eating and breathing
- Consider chair position, widening of PDL, tongue fibrosis, problems with hygiene
- Implants can be recommended (fixed better than removable)
Progressive disease that affects nerve cells in the brain and spinal cord, causing muscle atrophy and degeneration of spinal chord. Results in respiratory failure and death.
- ALS, amyotrophic lateral sclerosis
- Unknown cause, no muscle nourishment
Side effects of methotrexate?
- Ulcerative stomatitis
- GI toxicity with NSAIDS
What are the 2 main complications in pregnancy?
- Preclampsia - HTN and Proteinuria
- Can cause death from heart disease, severe complications, coagulopathy, renal/hepatic failure, pulmonary edema
- Gestational diabetes - usually after the 20th week, hormones influence insulin
What can the use of Mepivacaine cause in pregnant women?
- Fetal bradycardia with the use of Carbocaine.
- No evidence of periodontal disease and low birthweight