special patient final exam

infant exams

• knee-to-knee exams using caregiver assisted stabilization

• with caregiver to provide emotional and physical support

12 months

• first dental visit should be no later than __ __ of age

• child dental visits allow provider to establish rapport, provide appropriate education, administer preventative therapy, and continued relationship through life

barriers to care for children

• provider accessibility

• financial

• parent/caregiver oral health literacy level

• language

early childhood caries/severe early childhood caries

• preventable with appropriate supervision, diet, and preventive homecare

• risk increased with frequent sugar exposure, bedtime bottle containing milk or juice, and prolonged feeding patterns (breastfeeding and more etc)

anticipatory guidance

• is when a provider counsels parents on physical, psychological, and emotional milestones to prepare them to guide their child through these events. this should occur at each visit and will change as the child ages.

• guides parent on recognizing when there is a delay in development or something unordinary

sexual abuse

• if you have a child patient who has bruising on the soft palate what would you expect?

pediatric caries risk assessment

• identify factors that may contribute to caries activity and protective factors present

• individualize care to guide recall intervals, fluoride, and radiographic decisions

• ex: if a patient had a very low caries risk they would only need dental examination every 12 months

pregnancy

• clotting factors increase

• immune suppression so body does not reject fetus

• enlarged uterus in the third trimester may cause difficulty breathing (reduced expiratory reserve volume); avoid lengthy procedures and ensure patient is comfortable

• increased bleeding from hormonal changes and sensitivity may occur

periodontal disease and pregnancy

• linked to adverse outcomes

• periodontal infection can contribute to preterm birth, low birth weight, and preeclampsia

• disease may worsen due to hormonal and immune system changes

second trimester

• trimester of pregnancy preferred for treatment

• is often convenient for elective treatment, but necessary dental care an be provided throughout pregnancy

• sense of well-being

lichenoid drug reactions

• levantine

• quinidine drugs

• gold and mercury

• some antibiotics

• an inflammatory response in the oral mucosa resembling lichen planus, often caused by drugs, dental materials or allergens

effective daily biofilm removal pediatric patients

• is protective!

• tailor preventive guidance to caregiver ability and childhood development

intensify

• puberty, menses, pregnancy, and sex-steroid therapy can _ gingival inflammation and bleeding in the presence of biofilm

first trimester

• fatigue, syncope, postural hypotension

third trimester

• increased fatigue; discomfort, mild depression

• increased blood pressure during last month

• supine hypotensive syndrome

supine hypotensive syndrome

• seen in late pregnancy

• abrupt fall in blood pressure, bradycardia, sweating, nausea, weakness, air hunger seen while patient is in supine position due to compression of uterus on vena cava

• ask patient to roll onto left side to lift uterus and BP will return to normal

• reassess vital signs

osteoporosis

• skeletal disorder that compromises bone strength

• patients are predisposed to bone fractures

• primary osteoporosis: all genders and ages but most commonly follows menopause (loss of estrogen= increased osteoclast acitivty)

• secondary: medications and conditions

• low maxillary and mandibular bone density

osteonecrosis

• serious oral complication of cancer treatment

• blood flow to bone is disrupted, resulting in death of bone tissue. the bone can break down and the associated jaw will collapse

• previously associated with use of bisphosphonates and usually asymptomatic

• yellow/gray area surrounded by red (erythematous) tissue

normalization

• same opportunities and quality of life as others

access to care

• ability to obtain needed dental services

equitable care

• care and resources based on individual needs

inclusion

• being welcomed, accommodated, and fully included in dental care

pregnancy gingivitis

• exaggerated inflammatory response to local irritant and decreased OH with increased hormonal production

• inflamed margins and interdental papilla

• most common in second month

• progressed to fiery red and edematous papilla- tender to touch

pyogenic granuloma

• facial interdental papilla pregnancy tumor

• a benign growth on gingival tissue, often exaggerated by plaque found on interdental anterior papilla

• asymptomatic

• TB may aggravate

type I hypersensitivity reaction

• immediate IgE mediated hypersensitivity reaction

• caused by pollen, food, latex, or drugs

• patient may experience atopy; hay fever, urticaria, angioedema, itching, wheezing, hypotension, burning, dyspnea, rhinorrhea, conjunctivitis, chest tightness and in severe cases anaphylaxis

• occurs within MINUTES of exposure

• lesion may remain for 1-3 days

• treated with antihistamine (diphenhydramine/benadryl)

type III hypersensitivity reaction

• IgG and IgM mediated immune complex-medicated reactions

• caused by food, drugs, agents placed in mouth

• white, erythematous, or ulcerative lesions

• occurs within 24 hrs after contact

• up to a few weeks

• treatment includes removal of antigen, antihistamine for symptom relief. use topical corticosteroid in severe reactions

type IV hypersensitivity reactions

• T-cell mediated delayed hypersensitivity reaction

• caused by contact with allergen that may be found in dental materials, toothpaste, mouth rinses, lipstick, cosmetics, etc

• contact dermatitis; inflamed, blistered, dry, thickened, and cracked skin

• 2-3 days after contact with antigen onset

• 2-3 days after antigen removed duration

• treatment includes identification and removal of antigen with topical corticosteroids

severe type I hypersensitivity reaction

• position patient in supine position and maintain open airway

• administer oxygen and monitor vitals

• prepare to call EMS

• if angioedema with airway involvement activate EMS

• administer 0.3-0.5 mL of 1:1000 epinephrine by an intramuscular or subcutaneous injection

• provide 50-100 mg diphenhydramine (IV as needed) and begin CPR

wheel chair transfer

• position wheelchair in same direction as the dental chair

• lock the wheelchair brakes and remove footrests

• assist the patient by supporting their arms and guiding their weight during transfer

best way to prevent adverse reaction

• medical history review

• a medication history should capture prior reactions, their timing, and severity

specifically designated handicap parking

• when setting up a dental clinic for those with disabilities, what is most important to consider?

oral hygiene adaptive aids for those with physical impairments

• enlarged or extended handles, powered toothbrushes, strap or rubber band, bent handles

assessment of patient with physical impairment

• assess grip strength

• arm and hand range of motion

• mouth opening pattern

• tongue movement

• and ability to preform daily oral care

potential barriers for patients with physical impairment

• fear or anxiety from past negative experiences

• social stigma or embarrassment related to disability

• dependence on caregivers for transportation or communication

• financial limitations (low income or inadequate insurance)

• cultural or personal beliefs about seeking dental care

• communication challenges due to physical or sensory impairments

infective endocarditis (IE)

• infection of the endocardium or heart valves caused by microorganism

• patient may present with

  • fever

  • fatigue

  • new or changing heart murmur

  • positive blood culture

  • flu-like symptoms

  • dyspnea

• careful instrumentation, especially during SRP, reduces incidence of bacteria being transmitted

infective endocarditis etiology

• bacteria, most commonly streptococcus, staphylococcus, and candida that colonize damaged heart tissue or valves

patients at risk for infective endocarditis

• structural heart disease or prosthetic heart valves

• pre-existing heart valve abnormalities

• previous infective endocarditis

• intravenous drug use

• certain dental procedures

2 grams of amoxicillin 1 hour before procedure

• a patient comes in for DH treatment and has a prior history of infective endocarditis. What antibiotic prophylaxis and dose will they need?

hypertension

• persistent elevation of arterial blood pressure

• primary (essential): no identifiable cause and influenced by many factors

• secondary: results from an identifiable underlying medical condition or medication

  • often asymptomatic (silent killer)

  • elevated blood pressure

  • headache

  • dizziness

  • tinnitus

  • advanced disease may affect the kidneys, brain, heart, and eyes

primary hypertension risk factor

• 90%

• increasing age

• race/ethnicity

• family history

• obesity

• high sodium diet

• excessive alcohol consumption

• sedentary lifestyle

• reduced nephron number

secondary hypertension risk factors

• 10%

• chronic kidney disease

• endocrine disorders

• chronic steroid therapy

• medications (oral contraceptives, NSAIDs, decongestants, weight loss)

• illicit drug use

• obstructive sleep apnea

normal BP

• less than 120 and less than 80

elevated blood pressure

• 120-129 and less than 80

HTN stage 1

• 130-139 or 80-89

HTN stage 2

• 140 or higher or 90 or higher

hypertensive crisis

• > 180 and/or >120

ischemic heart disease (coronary heart disease)

• thickening of the innermost layer of the arterial wall due to accumulation of lipids that restrict blood flow of oxygenated blood into the heart

  • stable angina

  • unstable angina

  • myocardial infarction

• conditions occur when narrowed or blocked coronary arteries reduce blood and oxygen flow to the heart muscle (inadequate myocardial blood supply)

ischemic heart disease etiology

• oxygen deprivation secondary to reduced blood flow to a portion of the heart

ischemic heart disease presentation

• chest pain (angina pectoris)

• aching squeezing pressure or tightness in the mid-chest region radiating into the left should, left or right arm, neck, and mandible

• male gender, insulin, smoking, hyperlipidemia, diabetes, hypertension, and physical inactivity risk factors

extreme drop in blood pressure

Viagra or Cialis use in past 24 hours may lead to __ when combined with nitroglycerin, which is why we must avoid it.

160 systolic or 100 diastolic

• UTHSC blood pressure dismissal, elective treatment deferred

cardiac arrythmia

• an abnormal heart rhythm caused by electrical impulse that is generated or conducted improperly

• experienced by 5-15% of population

• prevalence increased with age, excess caffeine, hypertension, coronary artery disease, hypertension, heart failure, stress, some bronchodilators, antidepressants, and decongestants

medical assessment before elective DH treatment

• frequent angina at rest or with minimal activity requires ___

• may lead to myocardial infarction

conditions requiring antibiotic prophylaxis

• prosthetic cardiac valves or prosthetic material used for valve repair

• previous infective endocarditis

• certain congenital heart diseases

• cardiac transplant recipients who develop cardiac valvular disease

dental procedures requiring antibiotic prophylaxis

• manipulation of gingival tissue

• manipulation of periapical region of teeth

• perforation of the oral mucosa

50 mg orally 1 hour before

• child dose antibiotic prophylaxis

antibiotic prophylaxis in patients with an amoxicillin/penicillin allergy

• 2 grams /50 mg cephalexin or cefadroxil

• azithromycin or clarithromycin (500 mg /15 mg)

• doxycycline (100 mg/ 2.2 mg)

cardiac arrythmia signs and symptoms

• palpitations, dizziness, syncope, fatigue, chest discomfort, SOB

• some may be asymptomatic

• irregular heart beat

• slow heart rate (<60 beats/minute)

• fast heart rate (>100 beats/min)

• anxiety, fatigue, orthopnea, peripheral edema, tinnitus, visual changes

heart failure

• a condition in which the ventricles of the heart cannot adequately fill with or pump/eject blood to meet body’s needs

• left and right ventricular failures

right ventricular failure

• increased pressure and fluid retention, venous congestion, and peripheral edema

left ventricular failure

• increased peripheral resistance or myocardial disease leads to increased pressure and fluid retention, pulmonary hypertension, and edema

clincial presentation heart failure

• dyspnea in primary

• fatigue

• edema (swelling in legs, ankles, feet) due to inadequate venous return due to decreased output

• orthopnea (difficulty breathing while laying down) so patients may need to sit at semi-supine position

• cyanosis, clubbing of fingers, distended neck veins, peripheral edema

management of arrythmias

• pacemakers: small device that helps maintain a normal heart rhythm when heart beats too slowly or irregularly

• implanted defibrillators/implanted cardioverter defibrillator (delivers shock for life-threatening rhythm)

• radiofrequency catheter ablation (thin catheter that uses heat)

management of stable heart failure

• may include sodium restrictions and diuretics while decompensated disease warrant medical evaluation

stage C heart failure

• salt restriction and diuretics are recommended for treatment

medication management cardiac arrythmias

• fast sodium channel blockers

• beta blockers

• potassium channel blockers

• slow calcium channel blockers

left ventricular assistive devices (LVAD)

• mechanical pump that helps the weakened left ventricle pump blood to the rest of the body

• treatment

• requires pre-medication

dose needs to be decreased because drug can decrease metabolism of LA

• cimetidine can alter the metabolism of certain anesthetics. how may dosage of local anesthetic need to be adjusted for a patient taking acid-blocking drugs

day immediatley after dialysis

• if we have a patient that needs dialysis, when should they receive treatment?

peptic ulcer disease

• a sore or break in the lining of the stomach and/pr duodenum caused by damage from stomach acid and pepsin

• H. pylori bacteria is primary aggressive factor in development

• treatments include antibiotics combined with acid-suppressing medications

  • proton pump inhibitors, omeprazole, etc

• avoid NSAIDs, asprin, corticosteroids

inflammatory bowel disease

• is believed to result from an abnormal immune response in a genetically susceptible person, influenced by environmental factors and changes in the gut microbiome

  • ulcerative colitis

  • crohn’s disease

• oral or nutritional consequences

smoking and ulcerative colitis

• is associated with a lower risk

• nicotine may reduce intestinal inflammation and increase mucous production, strengthening intestinal barrier

• NOT recommended because overall health risks outweigh benefit

crohns disease

• affects anywhere in the mouth to the anus, but most commonly involved the distal ileum and proximal colon

• patchy inflammation (skip lesions)

ulcerative colitis

• affects the large intestine and rectum

• continuous inflammation

IBD management

• 5-aminosalicylic acid (ASA) for UC

• corticosteroids

• immunomodulators

• antibiotics

• biologics

• 5 children in a boat

pseudomembranous colitis

• severe and sometimes fatal form of colitis that results from overgrowth of clostridium difficile in the large colon

• risk results from use of broad spectrum antibiotics, specifically clindamycin

chronic kidney disease

• develops over time

• defined as kidney damage or decreased kidney function lasting > or = 3 months

• results from ongoing damage and loss of nephrons

• pallor (abnormal paleness of the skin of mucous membrane), pigmentation and of oral mucosa, xerostomia, dysgeusia, and halitosis

• infections: candidiasis, periodontitis, parotid infections

stage 3 chronic kidney disease

• symptoms usually begin to be evident where glomerular filtration rate is moderately decreased

stage 5 chronic kidney disease

• dialysis necessary

• GFR <15 indicative of kidney failure

• filters blood through a machine, patients cannot receive treatment on dialysis days

• medical consult required prior to treatment, avoid using arm with vascular access fistula to take blood pressure

• assess bleeding risk, anticoagulation, infection concerns, blood pressure throughout appointment and medication dosing

cancer therapy oral complications

• patients are prone to increased risk of secondary infections due to both immunosuppression and salivary gland disfunction

  • candida albicans opportunistic infection

• xerostomia, reduced salivary volume and increased viscosity (thick and ropy)

• mucositis

• dysgeusia

• increased risk for oral infections

consult with oncologist

• when treating a patient with who has completed cancer treatment, __ __ __ to confirm patient can receive treatment and their immune system is stable and recovering

alcohol and tobacco use

• combined together substantially increase oral cancer risk of squamous cell carcinoma

oral hygiene instruction for patient undergoing cancer treatment

• provide gentle oral care, appropriate soothing rinses for mucositis, and individualized pain management support

opioids and opioid-like drugs

• decrease pain perception

• produce mild sedation

• produce euphoria

• orthostatic hypotension may occur, likely due to peripheral vasodilation

naloxone

• opioid antagonist that rapidly reverses effects of opioid overdose

• attaches to opioid receptors to block or reverse effects of opioids

cocaine

• is a potent stimulant and vasoconstrictor

• may produce a sense of well being and intense euphoria, restlessness, agitation

• can trigger cardiovascular complications such as cardiac arrhythmias, tachycardia, mydriasis (pupil dilation), and elevated blood pressure

wait at least 24hrs

• before giving epinephrine with local anesthesia to a patient who has used cocaine

alcoholism

• cognitive impairment, memory problems and personality changes

• withdrawl may cause night sweats, hallucinations, and headaches

• glossitis, loss of tongue papillae, and angular cheilitis may be present with enlargement of the parotid gland and spontaneous gingival bleeding

amphetamines

• may cause violent behavior, hyperactive

• no treatment during use

• may cause xerostomia, severe and rampant caries, bruxism, clenching, erosion, periodontal disease

bacterial sexually transmitted infections

• gonorrhea

• syphilis

• treated with antibiotics

viral sexually transmitted infections

• herpes simplex virus

• infectious mononucleosis (caused by epstein barr virus)

• genital warts / HPV

states of herpes

• papular, vesicular, ulcerative stages and crusted stages

• delay elective treatment until lesions have healed to crusted stage when patient is considered noninfectious

• antiviral therapy may be needed to prevent treatment-associated recurrence

primary stage syphillis

• oral chancres on lips, tongue, and oropharynx, maybe swollen lymph nodes

secondary stage syphilis

• mucosal lesions, erosions, ulcerations, “snail track” ulcers may occur, maculopapular lesions, and white plaques resembling leukoplakia

tertiary stage syphilis

• oral gumma on tongue and palate; exophytic, indurated, and ulcerated

• palatal gumma may erode bone causing oronasal/oral antral fistula, atrophic/intestinal glossitis may occur

congenital syphilis

• hutchinson’s incisors or mulberry molars

• high narrow palate, skin fissures around mouth

HIV

• caused by human immunodeficiency virus, leading to progressive immune system impairment

• asymptomatic to AIDS presentation

acute HIV infection

• flu-like symptoms may occur (fever, fatigue, sore throat, swollen lymph nodes, headache, rash)

latent HIV period of infection

• HIV continues to affect the immune system but may cause few or no symptoms

• patient may appear healthy with some oral manifestations such as candidiasis, warts, or periodontal disease

AIDs

• advanced HIV infection

• immune system is severely weakened, making the patient vulnerable to opportunistic infections and certain cancers

• more severe or persistent oral conditions occur such as candidiasis, oral hairy leukoplakia, and necrotizing periodontal disease