dental management of patients with medical conditions (imp)

conditons that are considered as immune compromise

end stage kidney disease

end stage liver disease.

malignancies

untreated or end stage HIV infection

malnutrition

rheumatoid arthritis

psoriasis

inflammatory bowel

lupus

vasculitidies

organ transplant

does immuno compromised conditions require surgical antibiotic prophylaxis? (true/false)

true

what modifications does a pt with stroke need in their denture and which prosthesis should be considered in these patients?

1) thickened flange

2) implant borne prosthesis

(the patient should be healthy and should be able to maintain good oral hygiene)

what are the precautions in case of an epileptic patients

1) assess stability of their condition ( how frequently seizures occur and what triggers them )

2) consider the use of mouth prop to prevent the patient from biting the operators fingers or instruments if a generalized seizure occurs

antiepileptic drugs causing gingival enlargement

phenytoin

sodium valproate

carbamezepine

barbiturates

clinical features of trigeminal neuralgia

paroxysmal attacks of facial or frontal pain (few seconds - 2 minutes)

usually in morning

between paroxysms pt is usually asymptomatic

no neurological deficit

attacks are STEROTYPED in particular patient

pain (has 4 characteristics)

1) distribution along trigeminal nerve / branches

2) sudden intense sharp superficial stabbing /burning in quality

3) pain intensity (severe)

4) precipitation from trigger areas by daily activites (eating talking washing face shavig cleaning teeth)

which dental pain is very similar to trigeminal neuralgia

pulpitis

what shouldyou do if a patient with trigeminal neuralgia pain comes to your clinic ?

REFER the patient for MEDICAL ASSESSMENT

patients with unstable trigeminal neuralgia dental tretment can exacerbate the pain evenif done in a different area of the mouth

treating the AREA AFFECTED with LA Block can help reduce the degree of exacerbation

diagnostic test of trigeminal neuralgia

exclusion by

1) history

2) examination (nneurological assessment of cranialnerves)

3) investigations :- MRI (exclude space occupying demylinating disease)

4) Blood test to exclude infections and systemic vasculitis

ONLY THEN IDIOPATHIC TRIGEMINAL NEURALGIA AS A DIAGNOSIS CAN BE USED

MANAGEMENT OF TRIGEMINAL NEURALGIA

SYMPTOMATIC

reigonal local anaesthetic injection

DEFINITIVE

drugs that cause dry mouth

antidepressants

antipsychotics

psycho stimulants

selective serotonin reuptake inhibitors (SSRI)

SEROTONIN AND NONADRENALINE REUPTAKE INHIBITORS (SNRI)

DRUGS THAT CAN CAUSE BRUXISM

amfetamines

antipsychotics

if a psychotropic drug is causing an oral issue what do you do?

CONSULT a medical practitioner

ORAL CONDITIONS THAT CAN HAPPEN IN A PATIENT TAKING ILLICIT DRUGS

dry mouth

dental caries (cariogenic diet +lack of oral hygiene )

oral candidiasis and other oral infections

oral cancer intake of drugs through smoking)

bruxism , jaw clenching and resultant tooth damage (amfetamines and cocaine)

AT RISK OF DEVELOPING BENZODIAZEPINE DEPENDENCE

INSTRUCTIONS / PRECAUTIONS FOR ASTHAMATIC PATIENTS AND PATIENTS WITH COPD

bring their relieve inhaler and spacer to dental appointments.

SEVERE ASTHAMA increased risk from sedation and general anesthesia ( should be undertaken in ahospital with anaesthetist present )

rinse their mouth and throat with water after inhalation ( at risk for oral candidiasis secondary to use of inhaled corticosteroids )

patients are sometimes prescribed systemic corticosteroids (delay elective dental treatmet until the course is completed)

DO NOT PLACE PATIENTS WITH COPD IN A HORIZONTALPOSITION

NSAIDS that cabn be prescribed for asthamatic patients

NSAIDS that are contra indicated

COX 2 selective NSAIDS (CELECOXIB )

dont cause bronchospasm can be given in NSAID exacerbated respiratory disease

Non selective NSAID ( ASPIRIN , IBUPROFEN , NAPROXEN ) CAUSE BRONCHOSPASM AND ARE CONTRAINDICATED

FULL FORM OF COPD

chronic obstructive pulmonary disease

what is contraindicated in some patients with COPD

supplemental oxygen according to COPD action plan

placing them in horizontal position

Is snoring SIGN of OSA ( obstructive sleep apnoea)?

maybe ( needs a sleep laboratory investigation )

use of oral devices to treat snoring without medical examination is appropriate (TRUE/ FALSE)

FALSE ( if OSA is suspected always refer the patient for a medical examination )

in cases of OSA what sedation will you give the patient

pts with OSA have a increased risk of respiratory arrest from sedation and general anaesthesia and these procedures should be undertaken in ahospital under the care of an anaesthetist

what diagnosis is important in case of OSA

facial skeltal retrusion / RETROGNATHIA

construction of MANDIBULAR ADVANCEMENT SPLINTS ( MUST BE DONE in a MULTIDISCIPLINARY TEAM with a SPECIALIST RESPIRATORY PHYSICIAN )

SLEEP APNOEA

sleep related breathing disorder that involves a decrease / complete halt in airflow despite an ongoing effort to breathe ( muscle relax during sleep causing soft tissue in the back of throat to collapse and block upper airway)

HYPPNEAS

partial reduction in breathing

APNEAS and its mechanism

complete pauses in breathing ( 10-30 secs or some may go 1-2 minutes or longer )

leads to oxygen dropping to less than 40%

brain responds to lack of oxygen by alerting the body causing a breif arousal from sleep

CLINICAL FEATURE OF SLEEP APNOEA

Snores loudly and frequently with periods of silence when airflow is reduced / blocked

choking/snorting/gasping sounds when airway reopens

RISK FACTORS OF OSA

overweight (BMI 25-29.9)

Obese (BMI 30 and above )

CHILDREN with large tonsils and adenoid

Family member with OSA

ACROMEGALY AND HYPOTHYROIDISM

SMOKERS

large neck sizes ( 17 inch and above men

16 nch and above women )

middle age and older men and postmenapausal women

ethnic minorities

abnormalities of bone and soft tissue

DOWNS SYNDROME

abnormal morhphology rhinitis

nocturnal nasal congestion

EFFECTS OF OSA

fluctuating o2 levels

Increased heart rate

chronic elevation in daytime bp

increased risk of stroke

higher death rate due to heart disease

impaired glucose tolerance due to insulin resistance

impaired concentration

mood changes

increased risk of accidents (improper sleep )

disturbed sleep of partner

what is AHI

APNOEA HYPONEA INDEX

Types of OSA

MILD (AHI 5-15)

involuntary sleep during activities that require mild attention

eg WATCHING TV/READING

MODERATE (AHI 15-30)

involuntary sleepiness during activities that require some attention

eg MEETINGS/PRESENTATIONS

SEVERE (AHI>30)

involuntary sleepiniess during activities that require more attention

EG TALKING/DRIVING

TREATMENT FOR OSA

1)CPAP( CONTINUOUS POSITIVE AIRWAY PRESSURE )

2)ORAL APPLIANCE (LOOKS LIKE SPORTS MOUTHGUARD MAINTAIN OPEN /UNOBSTRUCTED AIRWAY )

3)SURGERY ( WHEN THERE IS OBVIOUS ANATOMY DEFORMITY BUT AFTER NON INVASIVE TREATMENT LIKE CPAP AND ORAL APPLIANCE HAS FAILED )

eg UVULOPALATOPHARYNGOPLASTY

ADENO TONSILLECTOMY

4) BEHAVIORAL CHANGES (WEIGHT LOSS , CHANGING FROM BACK TO SIDE SLEEPING )

5)OTC (over the counter ) REMEDIES

EXTERNAL NASAL DILATOR STRIPS

INTERNAL NASAL DILATOR

LUBRICANT SPRAYS

6)POSITION THERAPY

STAY OFF BACK AND RAISE HEAD

LIFESTYLE INDICATIONS of osa

management in middle aged people with osa

caution about alcohol intake (<7 drinks )

antismoking advice

avoidance of sleep deprivation

initiation of nasal steroids

positional therapy

weightloss program

refer for sleeptherapy if symptoms persist after lifestyle management

epworth sleepiness scale

mallampati score

oral anticoagulant drugs

apixaban

dabigatran

rivaroxaban

warfarin

injectable anticoagulant drugs

enoxaparin

heparin

(PRESCRIBED FOR A SMALL DURATION )

antiplatelet drugs (P2Y12 INHIBITORS )

aspirin

clopidogrel

prasugrel

dipyridamole

ticagrelor

INR

international normalised ratio indicates the extent of anticoagulation in patients taking warfarin (inhibits production of vit K dependant coagulation factors)

in dental practice the consequences of a thromboembolic event are usually more significant thant the consequences of bleeding (true/false)

true

non vitamin k antagonist oral anticoagulants (NOACs)

dabigatran (direct thrombin inhibitors)

apixaban /rivaroxaban (factor Xa inhibitors)

PATIENT RELLATED FACTORS THAT INCREASE THE RISK OF PROLONGED BLEEDING

ELEVATED BP

ABNORMAL LIVER/KIDNEY FUNCTION

PRIOR STROKE

HISTORY OF BLEEDING ESP WITH A SIMILAR PROCEDUE

PRE EXISTING BLEEDING DISORDER

POOR ANTICOAGULANT CONTROL(INR)

OLDER AGE OR FRAILITY

OTHER DRUGS THAT PREDISPOSE TO BLEEDING (NB1) INCLUDING NSAIDS (NON PRESCRIBED / LOW DOSE ASPIRIN )

HAZARDOUS ALCOHOL CONSUMPTON

ORAL AND DENTAL PROCEDURES UNLIKELY TO CAUSE PROLONGED BLEEDING

examination and diagnostic procedures (eg periodontal examination /impressions)

restorative treatments (restorations and rootcanal therapy)

orthodontic treatment

oral and dental procedures that are likely to cause prolonged bleeding (lower risk of prolonged bleeding )

extraction of small number of teeth (1to 3) that are NOT ADJACENT

periodontal procedures (9subgingival debridement )

incision and drainage of swellings

limited or small soft tissue biopsies

oral and dental procedures likely to cause prolonged bleeding (high risk of prolongrd bleeding )

extraction of a large number of teeth (4 or more )

extraction of adjacent teeth that creates large wound

mucoperiosteal flap (surgical extractions , implant placement periapical surgery , periodontal surgery )

extensive soft tissue biopsy

hard tissue biopsy

local haemostatic measures in patient taking anti thrombotic drugs

apply pressure to wounds

minimise tissue trauma

place cellulose and collagen

place sutures to enclose wounds.

consider usng tranexamic acid 4.8% mouthwash as an adjunctive measure for patient taking WARFARIN ( NO EVIDENCE FOR TRANXENAMIC ACID IN PTS TAKING NOACs)

10ml rinsed in mouth for 2 minutes then spit 4 times daily for 2 days

ADVICE PATIENTS TO SEEK URGENT MEDICAL ATTENTION TWITH PATIENT RELATED BLEEDING RISK FACTORS FOR PROCEDURES WITH A HIGHER RISK OF PROLONGED BLEEDING

ARRANGE A REVIEW DENTAL APPOINTMENT FOR 2 DAYS AFTER THE PROCEDURE

consider specialist referral for patients with patient related bleeding risk factors for procedures with a higher risk of prolonged bleeding (true/false)

TRUE

PARACETAMOL is the preffered analgesic for POSTOPERATIVE pain in patients taking anti thrombotic drugs (true/false)

TRUE (NSAIDs INCREASE THE RISK OF BLEEDING PATIENTS TAKING ANTITHROMBOTIC DRUGS )

ANTIPLATELET DRUGS

aspirin

clopidrogel

prasugrel

ticagrelor

dipyridamole

ANTICOAGULANTS

Apixaban

Dabigatran

Warfarin

Rivaroxaban

ANTIANGIOGENIC DRUGS

Sunitib

bevacizunib

ANTIRESORPTIVE DRUGS

biphosphonates

denusab (prolia)

denusab

PT IS ON TRIPLE ANTITHROMBOTIC THERAPY (2 ANTICOAGULANT +1 ANTIPLATELET)

FOR ANY ORAL AND DENTAL PROCEDURE REFER TO MEDICAL SPECIALIST FIRST FOR ADVICE

PT IS ON DOUBLE ANTIPLATELET ( OR )

PT IS ON SINGLE ANTICOAGULANT

CONSIDER SPECIALIST REFERAL BEFORE ANY THERAPY

1) PROCEDURES UNLIKELY TO CAUSE BLEEDING +PROCEDURES AT LOWER RISK OF PROLONGED BLEEDING

NO NEED FOR TEMPORARY PAUSE

2) PROCEDURES WITH LOWER RISK OF PROLONGED BLEEDING +PT HAS BLEEDING RELATED RISK FACTORS

AND

PROCEDURES WITH HIGHER RISK OF PROLONGED BLEEDING

CLINICAL ADVICE SHOULD BE TAKEN BEFORE PAUSING OR ALTERING MEDICATION

PT ON 1 ANTICOAGULANT AND ONE ANTIPLATELET

1) PROCEDURES UNLIKELY TO CAUSE PROLONGED BLEEDING

NO TEMPORARY INTERUPTION NEEDED

2) PROCEDURES WITH LOW RISK OF PROLONGED BLEEDING AND PROCEDURES WITH HIGH RISK OF PROLONGED BLEEDING

CONSULT CLINICIAN

PT ON WARFARIN

CHECK INR 24 HRS BEFORE PROCEDURE

INR 3.5 AND LESS PERFORM PROCEDURE

INR 3.5 AND MORE MEDICAL ASSESSMENT

PT ON SINGLE ANTIPLATELET THERAPY

1) PROCEDURES AT HIGHER RISK OF BLEEDING

MEDICAL REVIEW

2) PROCEDURES WITH LOW RISK OF BLEEDING

PROCEDURES UNLIKELY TO CAUSE BLEEDING

TEMP INTERUPTION NOT REQUIRED

PTS USING INJECTABLE ANTICOAGULANT

DELAY ELECTIVE PROCEDURES UNTIL AFTER ANTICOAGULANT USE

What dose of prednisolone will cause adrenocortical suppression?

Oral prednisolone at the dose of 10 mg or more daily (equivalent dose of other corticosteroid ) for more than 3 WEEKS .

ADRENAL CRISIS

patients with adrenocorticoid suppression or adrenal insufficiency are at risk of glucocorticoid deficiency during periods of physiological stress (significant systemic illness or surgery ) since usual response of increased corticosteroid production doesnt happen leading to ADRENAL CRISIS / ACUTE ADRENAL INSUFFICIENCY OR ADISONIAN CRISIS)

MANIFESTATIONS OF ADRENAL CRISIS

• GASTROINTESTINAL SYMPTOMS

• ACUTE CIRCULATORY FAILURE(HYPOTENSION / CONFUSION)

• SEVERE WEAKNESS

• LOW BP

• DEHYDRATION

• CONFUSION

• POTENTIALLY LOSS OF CONSCIOUSNESS

PRECAUTIONS IN CASES FOR PTS ON CORTICOSTEROIDS

• Perform dental treatment in the morning

• ensure pt remains in the care of an responsible adult for rest of day and carer remains in contact for 2-3days

• pts require an increased dose of corticosteroid (if required) for the procedure

when does the dose of steroid doesnt need to be increased?

in case of non invasive procedures like

• dental check

• Xrays

• impressions

when do we need an increased dose in cases of adrenal crisis?

usually on the morning of the procedure and pt has an dosing strategy or an action plan in place (if not refer a specialist)

done in cases of invasive procedures lasting less than 1 hr

• professional teeth cleaning

• restorative treatment

• tooth extraction

• periodontal treatment

• implant placement

when do we need to refer to a specialist in cases of adrenal crisis?

Invasive dental procedures longer than 1 hr

dental procedures requiring sedation , general anaesthesia or fasting

what is MRONJ?

Medication related osteonecrosis of the jaw

• area of exposed bone in jaw persisting for more than 8 WEEKS in a patient currently or previously treated by antiresorptive or antiangiogenic drug WHO HAS NOT RECIEVED RADIATION THERAPY TO CRANIOFACIAL REIGON

EXACT MOA OF ADRENAL CRISIS

STAGES OF MRONJ

RISK ASSESSMENT OF MRONJ