seminar shit + study casts

4 parts of CVS

• heart (organ to pump blood)

• arteries (thin muscular tubes that carry oxygenated blood away from heart to body)

• veins

• capillaries (connect v small arteries and veins. have very thin walls that allow o2, co2, nutrients and waste in/out of cells)

classification of cardiovasc diseases

anatomic

• heart diseases of

• pericardium

• myocardium

• endocardium

• heart valves

aetiologic

• congenital anomalies

• atherosclerosis, hypertension

• infectious diseases

details about infective endocarditis (DHCP)

• idetnify pt risk via specific qs

• consult w pt gp for AB prophy

• withhold instrumentation until med hx has been cleared

ab prophy

• administered post consult w pt gp

• prior to debridement, subging/supraging scaling

• reduce microbiome population prior to tx via antimicrobial mw

pt education

• instruction on oh selfcare

• biofilm instrumentation precedes instrumentation for scaling/debridement due to high incidence of bacteraemia before/after tx

• active discouragement of iv drug use

• regular checkup appts

congenital heart diseases

• anomalies structure of the heart or major blood vessels following irregularities of dev during first 9 wks in utero

• genetic or environmental cause or both

• ventricular septal defect

  • L and R ventricles exchange blood via opening in dividing wall (septum). so L o2 blood can go to R

  • severity related to location + size of defect

• patent ductus ateriosus

  • shunt presence btwn aorta and pulmonary artery

  • blood from aorta can pass back to the lungs

  • heart compensates in attempt to provide body w o2 blood - becomes overburdened

signs/symptoms of congenital heart diseases

• easy fatigue

• shortness of breath, fainting

• cyanosis

• poor g+d

• heart murmurs

• congenital heart failure

dhcp congenital heart defects

• prevention of infective endocarditis

• defective valves at ++ risk of endocard from bacteraemia produced during appts

• 2x/year dental exam + s/c

rheumatic fever + heart disease

• rheumatic heart disease is complication following rheumatic fever, presents 2/3 weeks after

prevention

• persistence + severity of pharyngeal infection are significant factors in determining whether RF follows

• early dx and tx of strep throat + pharyngeal infection are necessary

symptoms RF

• fever, abdominal pain, joint pain, chest pain

• nosebleeds, skin rashes, emotional instability, muscle weakness/jerking

symptoms RHD

• stenosis/incompetence of valves

• heart murmurs

• shortness of breath

• endocarditis and pericarditis

hypertension details

• primary and secondary

primary

• ~90% cases: tobacco, genetics, excess sodium, physical inactivity, lots alcohol

secondary

• ~10% casesrenal disease, sleep apnoea, drug/alcohol induced, meds

prevention

• control weight, exercise, reduce sodium intake, stop smoking, limit alcohol

hypertension symptoms/signs, dhcp

signs/symptoms

• early - dizziness, muscle cramps, weakness, snoring, edema

• long-standing - cerebral vascular accident, stroke, heart failure

dhcp

• use iv drug that has rapid onset and short duration of action - rapid control of BP

• sodium nitroprusside begins to reduce BP in minutes, but needs ongoing monitoring, blood tests, specialist, avoid pregnancy + kidney/liver impairment

• controlled/stable not problem in dental tx

• severe longstanding dental pain and severe anxiety associated with dental phobia can increase hypertension

• LA containing adrenaline does not have significant hypertensive effects

• NSAIDs should be used w caution as they can cause renal impairment

ischemic heart disease

aetiology

• reduced blood to myocardium - fat deposits thicken blood vessels. some plaques calcify, while others will develop overlying blood clot

risk factors

• inflamm of other body parts

• elevated levels of blood lipids, cholesterol, sat fat, carb, alcohol

• smoking, diabetes, emotional stress, age

manifestations

• angina pectoris

• myocardial infarction

• congen heart failure

angina pectoris

• need to make sure they’re stable and following preventive and rehabilitation program

• emergency treatment in the first 3 months after surgery

  • treat simply and non-invasively

• defer tx for 6 months after:

  • myocardial infarction

  • stent placement

  • coronary artery bypass surgery

• in the first 12 months, pts at increased risk of major adverse cardiac event

• pts with angina episodes should be told to bring meds to appts (glyceryl trinitrate spray/tablets)

• tx should be in short appts

• LA with vasoconstrictors is indicated

management angina or acute coronary syndrome
(hint: glyceryl trinitrate)

• make sure pts bring meds (glyceryl trinitrate) when coming for dental tx

• if chest pain occurs with history of angina

• stop tx, measure bp, hr

• use glyceryl trinitrate to relieve symptoms

  • 400 OR 300-600 mg subling, repeat every 5min if pain continues, total 3 doses if tolerated

• if pain for >10min with 2 doses, give 3rd dose and manage as severe/new chest pain

• dont continue with tx even if pt recovers, refer for med eval even if pt appears well

congestive heart failure

• abnormality of cardiac function responsible for inability/failure of heart to pump blood at rate to meet body’s needs of O2

symptoms

• fatigue, lightheaded

• shortness of breath

• confusion

• swelling/edema of legs, ankles, abdomen, neck veins

dhcp

• dental tx should only be done when heart failure is stable

• short appts

• pts need to place head higher than heart

• avoid NSAIDs bc can worsen heart failure

• if emergency - stop tx, call 000, start life support incl CPR

cardiac arrythmias

• interruption of conduction of heart impulses, causing delay/block

• symptoms: heart palpitations, fatigue, sweating

dhcp

• get detailed med hx

• vital signs assess

• consult w pt physician

• stress/anxiety must be minimised (prevent)

• LA w vasocont must be used sparingly (excessive epinephrine can precipitate arrythmia/other card complications)

cardiac pacemakers

• electrical devices in dent practices don’t interfere w contemporary pacemakers. but they do interfere with the telemetry (data transmission) without any effect on pt safety

dhcp

• be aware of pacemaker malfunction symptoms (breathing difficulty, dizziness, swelling in arm/chest, chest pain). cardiologist should be contacted if this occurs

• dont put electrical cords over pt chest

• unshielded pacemakers - used lead apron

• vasoconstrictors should be used w caution

• detailed med hx (specifics ab pacemaker, previous complications, meds)

• before therapeutic service, dentist should consult pt cardiologist

3 indications for antibiotics before dental surgery

1. surgical antibiotic prophylaxis

   • rarely indicated

   • only for pts with real bad immunity who need invasive dental tx - like 3rd molar surgery, implants, perio surgery etc

2. infective endocarditis prophylaxis

3. antibiotic to treat odontogenic infection

PT UNDERGOING WARFARIN THERAPY

• med hx and INR test

• before invasive dental procedure, note in med history dose regime, underlying med conditions/meds, and need for antibiotic prophy

• INR test within 24 hours of dent appt

  • <2.2 - proceed w tx

  • 2.2-4.0 - proceed with caution (use tranexamic acid mw)

  • >4.0 don’t do surgery and refer pt to med practitioner

• TARGET INR VARIES DEPENDING ON INDICATION FOR THERAPY AND INR SHOULDNT BE SOLELY RELIED ON FOR BLEEDING RISK

gingival hyperplasia and calcium channel blockers

• gingiva overgrowth one of the side effects of these blockers (for tx of hypertension, angina pectoris, cardiac arrythmia)

• disorder marked by abnormal gingiva growth (can start in interdental papillae and spreads to large area of tooth surface)

• favours accum of anaerobic bacteria - amplifying inflamm + accel connective tissue breakdown

• gingival enlargement may act as secondary risk factor - enhances bacterial dysbiosis and helping perio progress

perio disease and cardiovascular disease

• perio pathogens (p gingivalis, a. a) have been detected in artery atheromas. this implies direct microbial contribution to initiation + progression of atherosclerosis (leading to ischemic heart disease)

• has been proposed that immune cells are primed in chronically inflamed periodontium - more likely to be delivered to perivascular tissues through chemical movement mechanisms.

• recruitment process eventually leads to dev of hypertension/atherosclerotic disease

• perio pathogens actively secrete virulence factors - increases vascular damage and imbalance of host response

dhcp of perio and cvd

• perio pts should be advised to see physician to check for cvd signs (obvs within reason like if indicated)

• should be informed that perio linked w card complication risk

• OHI (checkup/clean, arrest perio disease)

• perio therapy - may have ++ impact on CV health

• perio is chronic condition which may aggravate cvd and requires lifelong attention/professional care

ASTHMA PT

• common meds used

• dental issues/oral findings

COMMON MEDS

• inhaled corticosteroids (fluticasone)

• long-acting beta2 agonists (salbutamol)

• sodium cromoglycate

DENT ISSUES/ORAL FINDINGS

• various stimuli : anxiety, infections, drugs/allergens

• >10% asthmatics sensitive to aspirin and NSAID’s (can cause bronchorestriction) - use paracetamol instead

• advise pts who regularly use inhalers to bring them to appts to self medicate

• oral candidiasis secondary to use of oral inhalers

• advise pts to rinse w water + spit after inhalation to reduce risk of candidiasis and systemic absorption of corticosteroids

mild/moderate asthma attack management

• give 4 puffs of salbutamol inhaler w spacer,

• ask pt to take 4 breaths in and out of spacer after each puff

• wait 4 min

• if lil/no improvement, give another 4 puffs

• assess pt status, if no improvement, manage as severe attack

severe asthma attack management

• call 000, start oxygen and airway support if u need to

• give salbutamol inhaler via spacer

  • adult + >6yo child: 12 puffs

  • child <6yo: 6 puffs

• reassess within minutes, repeat as needed, if life threatening, continue technique

• monitor pt

• if pt recovers quickly - stop tx, make another appt to complete tx if u need to, discharge from care while pt breathing easy, advise pt to take meds as prescribed and seek med review

COPD (chronic obstructive pulmonary disease)

• medical history

• oral findings

• dental hygiene care plan

MED

• progressive airflow obstruction that isnt fully reversible - associated with abnormal inflammatory response of the lungs

• combo of emphysema and airway damage

• smoking is major causative factor

ORAL FINDINGS

• pts may develop candidiasis secondary to use of inhaled corticosteroids

• advise pts to rinse mouth+throat w water after inhalation

DHCP

• severe COPD pts can’t lie flat

• pts taking systemic corticosteroids require increased dose before tx if have adrenal suppression

• smoking cessation only intervention to improve COPD

respiratory diseases dhcp

BEFORE TX

• remind pt to bring inhaler

• assess risk - review hx, episodes and triggers

• confirm usual meds taken

• evaluate symptoms - don’t proceed if abnormal

• schedule short, morning appts

• provide stress-free environment

DURING TX

• position pt upright/semi-upright

• antimicrobial pre-procedural rinse

• avoid power scalers/air polishers

• maintain effective high volume suction

• allow rest breaks as needed

• monitor for respiratory distress signs

• rubber dam - place w caution

• reinforce OHI

AFTER TX

• document all modifications

• recall in 3-6 months

dental implications of iron deficiency anaemia

• review med hx (iron therapy, supplements, control underlying cause of blood loss)

• short appt

• diet counselling (dietician referral)

• liquid iron supplements can cause teeth staining/rinse mouth, use straw

megaloblastic anaemia dental implications

• review med hx

• diet counselling (increase vit B12 intake - diet, injections, supplements)

• short appt

• avoid nitrous oxide sedation

• tailor chair configurations

sickle cell oral findings, dental implications

oral findings

• pulp necrosis

• enamel hypomin

• pallor (buccal mucosa)

• facial/dental pain

• mandibular osteomyelitis

• numb chin syndrome

dental implications

• review med hx (organ complications, last crisis date, current meds/transfusion)

• physician consult (confirm disease control, AB prophy indication)

• stress reduction (short morning appts)

• LA - low dose of vasocon - avoid intravascular occlusion of RBC)

• regular hygiene appts and OHI

primary polycythaemia oral findings

• bruise easy

• vertigo

• fatigue

• migraines

• spontaneous ging bleeding

• submucosal petechiae

• purplish/red oral mucosa, gingiva, lips/tongue

secondary polycythaemia signs/oral findings

• signs reflect underlying condition (bc ++ RBC production from hypoxia - from COPD, heart disease, emphysema, smoking)

• gingival bleeding

• rare: oral lichen planus

primary/secondary polycythaemia dental implications

• review mhx

• consult w haematologist before invasive tx (eg subging debridement)

• stress reduction - short, morning appts

• bleeding precautions: local haemostatic measures, monitor post-op

• good OH/regular hygiene appts

leucocytosis / leukaemia

• this is high WBC count caused by inflamm, infection, trauma, exertion

• leukaemia is extreme cause of leucocytosis

signs/symptoms

• weight loss

• petechiae on skin

• gingival bleeding/enlargement

• delayed wound healing

implications

• consult GP/oncologist (check INR, platelet, and PMN count before invasive tx)

• avoid elective/invasive tx during neutropenic periods

• ensure pt dentally fit before chemo

• manage chemo oral manifestations (oral mucositis, xerostomia)

• monitor adverse effects

• regular dental recall program/reinforce good OH (gingival infiltration can mask plaque buildup)

bleeding/coagulation disorder oral findings, dental implications

oral findings

• gingival bleeding/exaggerated gingival response to irritants

• petechiae, mucosa pallor

• atrophic glossitis

• persistent infection/non responsive ulceration

dental implications

• consult haemotologist before invasive tx

• local haemostatic measures

• refer for med review if bleeding uncontrolled

haemophilia

dental implications

• review mhx (check pt’s australian bleeding disorders registry card)

• consult w haemotologist before tx

• avoid aspirin + NSAIDS

• routine hygiene care/preventative, generally safe in general practice

LA

• IAN block - risk of haematoma formation in pharyngeal space

• if its likely required - speak w haemotologist or refer to hospital based specialist dental team

clinical appt prep blood disorders

• INR documented + measured within 24hrs of invasive tx

• pt on anticoagulant, chemo, corticosteroid?

• hx of bleeding problem, clin signs of bleeding disorder?

dhcp - pt hx blood disorders

• mhx - type, severity, meds, family hx of clotting defect

• ask: bleeding after past tx, transfusion before 1990 (HepB/C, HIV risk), emotional stress, anxiety

• dental hx

• risk assess (address modifiable factors)

• meds and herbs review

physician/haematologist consultation (bleeding disorders)

• consult before invasive tx

• anticoagulants rarely stopped - clot risk (usually) > bleeding risk

• AB prophy confirm

• inherited disorder → factor replacement may preced appt

• request current blood test results

bleeding disorder + LA + post op

• use vasocont

• infiltration > blockes (blocks inc bleed risk)

• soft bristle brush + minimise tissue trauma → aspirating caution

• no aspirin + NSAID’s post-op

• review call post-op same evening to check bleeding

• frequent recall 3-6 months

importance of cancer to hygienists

• need to identify and prevent further progression of disease

• important to note that although some tumours are benign, doesn’t mean that they’re safe

  • location is important

  • growth continues - may press on vital organs and become another issue

oral complications of radiation therapy treatment

• oral mucositis

• dysgeusia (taste loss)

• xerostomia

• infections (bacterial/viral/fungal)

• radiation caries

• trismus

• osteoradionecrosis

pretreatment of cancer surgery (dental)

• conduct a pretx oral health examination

• schedule dental tx in consultation w oncologist

• extract teeth with poor/questionable prognosis at least 2 weeks before the start of cancer therapy

• do other necessary oral surgery procedures at least 2 weeks before the start cancer therapy

dental hygiene pretreatment considerations

• perform dental hygiene tx (NSPT, polishing, fluoride), before start of cancer tx

• evaluate pts oral health knowledge + provide appropriate oral hygiene regimen based on cancer management

• prevent demin/caries

• develop dental treatment in consultation w treating specialist/multidisciplinary

mucositis management

• prevention + oral hx maintenance

  • interdental cleaning technique should be taught (can be precluded during chemo)

  • use bland mw (like saline) 3/4x a day

  • diet mod - no rough/sharp foods

  • avoid alcohol/tobacco

  • cryotherapy (ice chips held in mouth right before and after chemo agent is given)

• palifermin (can be prescribed for severe)

treatment of mucositis

• symptomatic relief

  • sodium bicarbonate powder, 1/2tsp dissolved in glass warm water rinsed + spat out

• OR

  • lidocaine 2% viscous soln, at lowest dose necessary up to 15mL, rinsed in the mouth for 30 seconds, then spat out, 3x/hr (max 8 doses in 24hrs

• if pain + discomfort restrict OH, use antiseptic mw

  • chlorhexidine 0.2% 10mL for 1 min, 8-12 hourly (dilute w water if stinging)

  • chlorhex 0.5% gel - apply 2-3 times daily to all mucosal surfaces and ging margins

xerostomia and cancer tx

• develops due to significant salivary flow reduction from radiation therapy

• sip water frequently

• use saliva substitute spray/gel, prescribed saliva stimulant

• avoid hot, spicy, sharp, salty foods

radiation caries management

• use fluoridated TP (5000ppm) for high risk

• CPP ACP for home application

• fluoridated mw

• clinical topical application of fluoride

• aim for low caries diet

osteoradionecrosis (cancer)

• characterised of area of exposed bone in jaw >8weeks

• radiation induced hypoxia, hypovascularity (reduced blood supply), hypocellularity are root causes

• risk factors

  • ill fitting dentures

  • bone malignancy

  • radiation

  • use of cancer regimens containing drugs that increase risk

  • poor OH

  • smoking/alcohol

• choose conservative dental tx (perio, resto, endo)

• don’t extract before/after head/neck radio without consulting multidisciplinary team

• management

  • non-surgical and surgical managements are available to treat ORN

trismus

• reduced ability to open jaw due to radiation induced fibrosis (thickened scar tissue around masticatory apparatus)

• management

  • reinforce OH

  • monitor pt for trismus, check for pain/weakness in masticating muscles in radio field

  • instruct pt to exercise 3x/day, opening/closing as far as possible wo pain, repeat 20 times

  • physio

  • trismus devices can also be used - but should be used w experienced clinicians

cancer dental considerations

• get medical clearance from oncologist after cancer tx - say that pt now fit for dental tx

• info ab immunosuppression and whether ab prophy indicated or not

• pt should visit every 3 months (not 6) - radiation side effects are long lasting

• trismus pts - shortened and in morning, reduce stress levels, frequent breaks

factors to teach pt - cancer

• how to exercise jaw muscles 3/xday, prevent + tx jaw stiffness

• diet mods important

• why hygienist needs to do oral soft tissue screening and complete oral exam at frequent intervals

• report any changes in oral cavity to oncologist and/or dental hygienist/dentist

• how to use personal oral care control methods to reduce side effects

psychotropic medications

• antidepressants, antipsychotics, psychostimulants - can cause adverse effects (eg dry mouth, bruxism)

• when combined w cariogenic diet + lack of oral hygiene - can lead to caries, oral/pharyngeal candidiasis, infections

• consult pts medical practitioner if med suspected to be causing oral adverse effect

• LA containing adrenaline aren’t contraindicated with tricyclic antidepressants or selective serotonin reuptake inhibitors, but should be avoided in pts taking MAO’s (monoamine oxidase inhibitors)

oral implications anxiety

• xerostomia related to medications put pt at high risk for dental caries

• individuals with diagnosis at higher risk of tooth loss

• mental hx disorders have 25% higher caries risk

• significant association btwn perio and emotional disorders (anxiety and depression)

• pt w OCD may perform excessive, vigorous tbing resulting in gingival/tooth abrasion

appt considerations for anxiety

• review med hx and meds

• enhance pts sense of control

• cognitive distraction: encouraging the pt to think ab something besides dental tx

• nitrous oxide sedation may help calm pt

• effective pain control

• schedule appts in morning, eliminate unnecessary waiting in reception

• keep in mind symptoms of panic attack, take breaks

dhcp for depressive disorders

personal factors

• self care impairment and lack of motivation -vely impact OH

• difficulties with memory - may need to be considered when planning tx

• poor diet quality such as higher intakes of energy-dense foods that tend to be higher sugar - inc risk of dental caries and impact healing after periodontal therapy

oral implications

• xerostomia + poor diet choices (inc biofilm)

• omission of general health habits and neglect of oral care make person susceptible to oral diseases

• taste perception changes may contribute to preferences for sweet/refined sugar, resulting in intake almost twice that of those without depression

appt interventions

• Assessment - monitor medical/meds closely

• Approach - positive reinforcement + reassurance

• Preventive instruction - dental biofilm control + xerostomia management

• implementation of care plan - adjust light carefully and give tinted eyewear for photosensitive pts

dhcp for bipolar disorder

personal factors

• in a manic episode

  • many patients talk quickly, jump from thought to thought, short attention span

• in a depressive episode

  • pt may not be interested in oral self-care and be unmotivated

oral health implications for bipolar disorder

• poor OH, as often is not priority

• gingival tissues may appear abraded and lacerated because of overzealous toothbrushing w excessive pressure

• higher caries risk/perio disease

• severe tooth wear

• vasoconstrictors should be used w caution w risperidone and consult w primary care provider is recommended

appointment interventions - bipolar disorder

• carefully review medical and medication hx

• simplify surroundings

• prioritise risk factors and use direct, simple instructions

• when applicable, help pt caregiver to learn procedures of caries prevention/perio health

• based on caries/perio risk assess, prioritise and implement management strategies - like in-office and home fluoride application, diet counselling, chlorhex mw

• shorter continuing care appts - prevent + manage oral disease

feeding/eating disorders - dhcp

• anorexia nervosa

  • frequently engaged in excessive exercise + preoccupied with food/weight loss

  • person is high achiever + highly motivated scholastically, may be socially isolated/withdrawn

  • suicide risk increased

• bulimia nervosa + binge eating disorder

  • pt aware habits are abnormal, may suffer low self-esteem and guilt

oral implications - feeding/eating disorders

• dental erosion - by acid vomiting/GERD

• self induced 5x risk of erosion

• restos in pos teeth may appear raised bc of erosion around margins

• inc in dental caries particularly in cervical areas

• mucosal lesions - angular cheilitis, glossitis, inflamm of pharynx, burning sensation

• gingival trauma - compulsive tbing may predispose to recession + bone loss

• perio manifestations

  • saliva - decrease quantity, quality, pH of saliva limits its buffering and lubricating properties

  • xerostomia

  • hypersensitive teeth

  • trauma - soft palate, pharyngeal trauma, callus formation/scars on fingers/knuckles

• parotid gland - enlargement may occur within days after binge-purge event

• bruxism - tooth wear associated w GERD

• taste perception may be impaired

• TMJ disorders - self-induced vomiting

appt interventions - feeding/eating disorders

• approach pt with nonthreatening/judgemental demeanor

• denial of eating disorder is common

• answers to med/perosnal questions of diet/laxatives, diuretics may give suspicions of eating disorder

• assess nutritional status through dietary assessment

• record vital signs

• improvement in OH

• don’t brush after vomiting

• remin after vomiting w alkaline rinse of sodium bicarb soln

• management of dental hypersens

• xerostomia management

schizophrenia oral implications

• overall degen of health may have occurred (neglect diet, exercise, sleep, general cleanliness, oral care)

• concurrent alcohol and/or drug abuse, + smoking can influence dental/perio hx

• higher rates dental caries, more missing teeth, fewer filled teeth (either lack of access to dental care/failure to seek dental care)

• xerostomia coupled with lack of attention to self-care may lead to increase in dental caries

• higher attachment loss, may be result of lack of self-care couples with lack of dental care + tobacco use

appt planning/interventions schizophrenia

• effective tx can’t be done until schizophrenia is stable

• patient decompensates (eg hallucinates/exhibits bizarre behaviour, immediate referral needed)

• phone numbers of pts mental healthcare provider should be kept in easily accessible location for quick referrals

• planning essential

• review med hx/meds, analyse meds for side effects

• consult w med healthcare provider for meds, alcohol/substance use

• negative symptoms associated w poor oral health and greater need for perio tx

• plan simple routine

intervention for mental health emergency

• stay w pt, request colleague contact, or other responsible person

• maintain calm, serene manner, talk quietly but firm

• move pt to quiet, less stimulating environment (environ/equipment may have contributed)

• if pt might be suicidal - try to remain calm and implement BeThe1To

be the 1 to (suicide)

1. be the 1 to ASK: directly ask pt if theyre thinking ab suicide. asking in a direct manner can open the door to the pt sharing feelings

2. be the 1 to KEEP THEM SAFE: showing support for someone can put time and distance btwn person and their chosen suicide method

3. be the 1 to BE THERE: being present shows support for at risk person, this can be lifesaving

4. be the 1 to HELP THEM CONNECT: call suicide prevention lifeline. call will help you w resources available to assist and pt willing to talk to mental health professional

5. be the 1 to FOLLOW UP: following up to see if pt is okay has been known to reduce the no of suicide deaths