Session 1: DTP - overview of diagnostic process, pt presentation and clinical considerations

patient database, standardized method

• start of diagnostic process - info gathering + clinical tools + eval → dx list

• develop consistent method

primary method for gathering pt hx

• questionnaires and forms

• pt interviews

secondary method for gathering pt hx

requesting info from another healthcare provider

six steps of medically complex risk assessment

1. assess med status

2. review meds and tests

3. assess dental and oral health

4. discuss pt concerns consult if needed

5. plan safe tx

which ASA status?

healthy, nonsmoking, no or minimal alcohol use

I

which ASA status?

mild systemic disease,no functional limitations, well-controlled conditions:

• current smoker, social alc use

• pregnancy

• class I obesity: BMI 30-40

• well controlled DM/HTN

• mild lung disease

II

which ASA status?

severe systemic disease, some functional limitations, poorly controlled:

• poorly controlled DM/HTN, COPD

• Class II morbid obesity: BMI ≥ 40

• active hepatitis

• alc dependence/abuse

• implanted pacemaker

• moderate ↓ ejection fraction (EF 30-50%)

• ESRD: require dialysis or kidney disease

III

which ASA status?

severe systemic disease, constant threat to life

• recent <3mo serious conditions

• ongoing cardiac ischemia

• severe ↓ ejection fraction (EF <30%)

• sepsis

• DIC

• ARDS

• ESRD not on dialysis

IV

which ASA status?

moribund pt, not expected to survive w/o operation: ruptured aneurysm, massive trauma, intracranial bleed w mass effect, ischemic bowel, or multiple organ/system dysfunction

V

which ASA status?

declared brain-dead pt, organ donation

VI

asthma classifications:

• mild-intermittent

• mild-persistent

• moderate-persistent

• severe-persistent

elective dental care bp under

160/100

emergency dental care bp under

180/110 and monitor every 10-15 min during tx

how long should you wait before taking blood pressure?

5 minutes (no convo, arm at heart level, bare arm, back supported and legs uncrossed)

oral health relevance of autoimmune disease?

• salivary glands, mucosa, jts, bnes

• increased risk of infection, caries, perio disease

• tailored dental management strats

common autoimmune disease w dental relevance

• sjogren’s

• RA

• SLE

• Crohn’s

• Type 1 diabetes

oral manifestations of Sjogren’s

• xerostomia)

• increased caries

• oral candidiasis

oral manifestations of RA

• TMJ dysfunction

• limited mouth opening

• difficulty with hygiene

oral manifestations of SLE

• Oral ulcers

• mucosal inflammation

• delayed healing

oral manifestations of Crohn’s

• swollen gums

• deep ulcers

oral manifestations of type 1 diabetes

• perio disease

• dry mouth

• delayed healing

challenges in dental therapy consideration

• Reduced saliva complicates procedures

• Joint pain may limit access and cooperation

• Immunosuppressive medications increase infection risk

management strategies in dental therapy considerations

• Use saliva substitutes and fluoride treatments

• Modify chair positioning and appointment length

• Collaborate with physicians for medication timing

• Emphasize preventive care and frequent recalls

small glands above the kidneys that produce the hormones: cortisol, aldosterone, and adrenal androgens

adrenal gland

key functions of the adrenal gland

produce hormones that control:

• stress response - cortisol

• bp and Na balance - aldosterone

• metabolism - cortisol

• fluid balance - aldosterone

• secondary sex characteristics - adrenal androgens

clinical relevance of adrenal insufficiency

do not produce enough hormones, particularly cortisol and sometimes aldosterone, which are essential for regulating metabolism, immune response, and blood pressure

patients may not tolerate stress well and may require steroid supplementation during dental care

adrenal glands typically release (x-x) mg of cortisol/day which is the equivalent of 5-7.5mg of prenisolone in a rhythmic pattern

24-30mg

during severe stress cortisol production may increase to (x) mg/day which is about 60mg of prenisolone

300

long-term use of exogenous glucocorticoids (prednisolone, dexamethasone) suppress hormone secretion through negative feedback, causing he adrenal glands to reduce their natural cortisol production aka…

adrenal suppression

what drug class?

warfarin aka coumadin

anticoagulant

what drug class?

• clopidogrel (Plavix)

• aspirin

• ticlopidine (ticlid)

• prasugrel (effient)

• ticagrelor (brilinta)

antiplatelet agents

what drug class?

• rivaroxaban - xarelto

• apixan - eliquis

• dabigatran - pradaxa

• edoxaban - savaysa

direct-acting oral anticoagulants (DOACs)

pts taking warfarin (continue/discontinue) their anticoagulant therapy before uncomplicate dental extractions

can generally continue

why continue warfarin for uncomplicated dental exts?

risk of thromboembolism may outweigh the risk of bleeding

blood clot (thrombus) forms in a blood vessel and travels (embolizes) through the circulatory system, potentially blocking blood flow to vital organs like the lungs (pulmonary embolism), brain (stroke), or heart (heart attack)

INR and dental exts: INR ≤ 3.0

well supported as safe for dental exts

INR and dental exts: INR ≤ 3.5

considered safe for most uncomplicated oral surgical procedures

INR and dental exts: INR up to 40

considered acceptable by some experts

PT and PTT → extrinsic vs intrinsic pathways

• PT (Prothrombin Time) measures the extrinsic pathway of coagulation (factors I, II, V, VII, X) and is used to monitor Warfarin therapy; low-acting oral anticoagulant that inhibits vitamin K-dependent clotting factors (II, VII, IX, X)

• PTT (Partial Thromboplastin Time) assesses the intrinsic pathway (factors I, II, V, VIII, IX, X, XI, XII) and is used to monitor Heparin therapy; fast-acting anticoagulant that enhances antithrombin activity IIa and Xa)

define: sudden, uncontrolled electrical disturbance of the brain. This may produce a physical convulsion, minor physical signs, thought disturbances, or a combination of symptoms

seizure

In 2015, (?)% of the U.S. population had active epilepsy

1.2%

chronic neurological disorder characterized by recurrent, unprovoked seizures

epilepsy

seizures are the hallmark of epilepsy but could also result from

other conditions, such as infections, stroke, brain tumors, head injuries, low blood sugar, or alcohol and drug withdrawal

aka not all seizures indicate epilepsy

what to do if someone is having a seizure

how to prevent seizures in dental practice?

1. know pt’s hx

2. identify and avoid triggers

3. optimize dental environment

4. recognize early signs and act

what is SBE?

Subacute Bacterial Endocarditis, a slower, less severe form of infective endocarditis (infection of the heart’s inner lining or valves) caused by bacteria like Streptococcus viridans or Staphylococcus.

dental procedures (even routine cleanings) can introduce bacteria into the bloodstream, posing a risk for patients with heart valve defects, artificial valves, or a history of endocarditis—often requiring antibiotic prophylaxis before invasive treatments

what are the four cardiac conditions that require antibiotic prophylaxis before dental procedures?

1. prosthetic heart valves

2. hx of infective endocarditis

3. certain forms of congenital heart disease (CHD)

4. heart transplant pts who develop valvular disease

firstline antibiotic for odontogenic infections or infective endocarditis/SBE

amoxicillin 2g - broad-spectrum bactericidal

if pt allergic to firstline antibiotic what else can they take?

if allergic to penicillin or ampicillin cephalexin 2g OR azithromycin/clarithromycin 500mg OR doxycycline 100mg

cephalexin and cross rxn to penicillin

first-generation cephalosporin antibiotic, and while it has a structural similarity to penicillin, the risk of a cross-allergic reaction is low but not zero—estimated at about 1–3% in patients with a penicillin allergy

t'/f: prophylactic antibiotics are NOT necessary for most pts w jt replacements prior to dental procedures including cleanings, restorations, or exts unless other significant medical conditions

true

If a patient’s physician advises antibiotic coverage for a dental procedure that does not fall under the AHA- recommended conditions, the responsibility for prescribing the antibiotic lies with

the physician

firstline antibiotics for tooth infection include (3)?

• amoxicillin

• cephalexin

• azithromycin

tooth infection: acute or chronic infection?

acute

TID vs q8h

three times daily vs every 8 hours

qd, bid, tid, qid

• 1/day

• 2/day aka q12h

• 3/day aka q8h

• 4/day aka q6h

autoimmune condition where body attacks and destroys the insulin-producing beta cells in the pancreas, resulting in little to no insulin production

type 1 diabetes

condition in which the body becomes resistant to insulin or does not produce enough insulin leading to elevated blood sugar levels aka body does not use insulin well or makes to little

type 2 diabetes

HbA1c < 7%

ideal for dental procedures

HbA1c 7-8.5%

• proceed w caution

• monitor healing closely

HbA1c > 9%

• avoid elective procedures

• focus on non-invasive care and infection control

• consult w pt’s physician before proceeding

safest trimester for procedures

second 14-28

elective that can be deferred should be postponed

emergencies like extractions, root canals, restorations can be performed

radiographs and anesthesia can be used; radiographs w abdominal and thyroid shielding but no “routine” radiographs and instead BW, panos, or select PAs recommended

which anesthetics are safest for pregnant pts?

lidocaine + epi AND prilocaine which are class B

which anesthetics are class C for pregnant pts?

articaine, bupivacaine, mepivacaine still safe just not first choice

MRONJ

• medication-related osteonecrosis of the jaw

• exposed bone in jaw that does not heal w/in 8 weeks

risk factors of MRONJ

• medication type, dose, tx duration indication

• higher risk in cancer pts receiving high dose antiresorptive therapy compared to pts tx-ed for osteoporosis

what are some common meds associated w MRONJ?

bisphosphonates:

• zoledronic acid - zometa

• alendronate - fosamax

• risedronate - actonel

RANKL inhibitor:

• denosumab - xgeva, prolia

RANKL is a protein that stimulates osteoclasts or osteoblasts?

stimulates osteoclasts, bone-resorbing cells

how does denosumab work?

• blocks RANKL reducing bone resorption but MRONJ risk

• IV zoledronic acid risk: - 0.3-5%

• denosumab risk: 0.7-1.9%

clinical consideration MRONJ

• preventative dental care - encourage excellent oral hygiene and regular dental checkups

• before therapy complete necessary invasive procedures and allow adequate healing time before therapy

• avoid invasive dental procedures during therapy, use least traumatic technique and achieve primary closure

• communicate w pt, pt’s physician, oncologist, prescribing provider

• monitor and follow-up

what ae four ab results recommended for dental care?

1. CD4+ T-cell count

2. HIV viral load

3. CBC - anemia, leukopenia, neutropenia!

4. coagulation profile (PT/INR, a PTT) - if retroviral therapy

if CD4 count is <(?) cells/mm³ there is an increased risk of infection and may require antibiotic

200

liver disease and dental tx

• liver disease can affect bleeding risk, metabolism of meds, body ability to fight infection

• hep B (HBV): transmitted through blood and body fluids, pts may be acute or chronic carriers

• hep C (HCV): transmitted mainly through blood, often chronic w liver involvement

lab tests for important dental care

• LFTs: AST, ALT, ALP, bilirubin, albumin

• PT/INR

• platelet count

zolof aka sertraline

selective serotonin reuptake inhibitor (SSRI) commonly prescribed to treat depression, anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

In dentistry, Zoloft may influence dental treatment by:

• Increasing the risk of bruxism or xerostomia

• Potentially affecting bleeding risk

• Interacting with local anesthetics containing epinephrine in patients with cardiovascular concerns (due to its effects on heart rate and blood pressure)

average respiratory rate

12-20

schedule dental tx tx before/one day of/after dialysis

day after