History of Endodontics aae/abe



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Normal Lab Values
Platelets:

  • Normal: 150,000 – 450,000 cells/L

  • Surgery: > 50,000 cells/L

PT (Prothrombin time):

  • Tests Extrinsic (VII) and common pathway

  • Normal: 11-15 s

aPTT (Activated partial thromboplastin time):

  • Tests Intrinsic (VIII, IX, XI, XII) and common pathway

  • Normal: 25-35 s

TT (Thrombin time):

  • Tests ability to form initial clot from fibrinogen (end of common pathway)

  • Normal: 9-13 s

INR Value:

  • Standardized Ratio of patient’s PT to control PT, measures Extrinsic (VII) and common pathways, measured index for Coumadin therapy/risk of bleeding

  • Normal: 0.8-1.2 (< 1.0), Coumadin: 2.0-3.0 (< 3.0)

Normal Lab Values
CBC:

  • RBCs

  • WBCs

  • Hemoglobin

  • Hematocrit

  • Platelets

Sed rate: 1 – 40 mm/hour


WBC: 4,000-11,000 cells/L

Neutrophil count: > 500 cells/L


Cancer & Oral Care
Chemotherapy & Dental Considerations: Myelosuppresion

  • Thrombocytopenia – Prolonged bleeding - Local measures, Platelets

    • Infusions – Platelets <50,000 cells/L

  • Leukopenia – Risk of Infection – Antibiotics (prophylactic + 7 d. course)

    • WBCs < 1000 cells/L

    • Neutrophils < 500 cells/L

    • Culturing/Ab sensitivity testing of exudate

  • Anemia – Weakness, Hypotension – Blood transfusions

  • Emergency Tx ONLY during Chemotherapy!


H&N Radiation & Osteonecrosis:

  • Avoid Sx in patients who received > 6000 cGy

  • Avoid EPI, Avoid Lidocaine

  • Surgery - Pen VK – Prophylaxis and 7 day regimen

  • Hyperbaric Oxygen prior to Sx/Invasive Tx – improve wound healing

Cancer & Oral Care

Common chemotherapeutic agents:



  • Methotrexate:

    • MOA – Anti-metabolite, Anti-folate

    • Uses - cancer chemotherapy (high doses), autoimmune diseases – Rheumatoid Arthritis, Lupus, Crohn’s disease (low doses)

    • Side effects – Ulcerative stomatitis (oral ulcerations),  WBC/ infection risk, abdominal pain, nausea, acute pneumonitis

    • Drug interactions: (PNPV)

      • Penicillins -  elimination,  toxicity

      • Nitrous Oxide – hemo toxicity

      • Proton pump inhibitors (ie: Omeprazole) -  toxicity

      • Valproic acid -  toxicity

  • Cyclophosphamide – alkylating agent, DNA replication, severe side effects

  • 5-fluoruracil – Anti-metabolite, severe myelosuppression, CNS damage

  • Doxorubicin – anthracycline antbiotic, intercalating DNA, cardiomyopathy, CHF

Neurologic Diseases

Epilepsy/Seizures

  1. Definition: Abnormal brain activity resulting in depolarizing shift

  2. Types: Convulsive (60% - focal/generalized), Non-convulsive (40%); Generalized (loss of conciousness): Tonic-clonic(rigidity/convulsions), clonic, myoclonic, absence, atonic

  3. Aura: sensory(visual/hearing/smell), motor

  4. Causes: brain trauma, stroke, tumors, idiopathic (60%)

  5. Medications: Phenytoin(Dilantin), Carbamezpine (Tegretol), Valproic Acid

  • GABA = sedative, CNS depression

  • Avoid: Benzodiazepines, Barbituates, & Alcohol due to effect on CNS/GABA

  1. Dental Considerations:

  • Medical Consultation: Type of Seizure, Last activity, PFs, Medications, Control

    • Well controlled: Routine Care

    • Poorly controlled: Med Consult, possible limitations

  • Avoid Aspirin/NSAIDs (valpr), Benzodiazepines/Alcohol/Opioids (CNS dep)

  • Limit Epi to 2 carps

  • Use ligated mouth prop

Neurologic Diseases

Epilepsy/Seizures

  • During Seizure:

    • Clear area, Protect patient, Suppine Position, Turn patient to Side (to avoid aspiration)

    • No padded tongue blade

    • Passively Restrain

  • Testing: EEG, CT/MRI Brain scan

Medications: Anticonvulants- carbamazepine, valproic acid, pre-gabalin (lyrica), gabapentin (neurontin) – other uses include neuropathic pain, neuralgia, migraines

Valproic Acid, Carbamazepine (Tegretol) adverse effects:

  • Nausea, blurred vision

  • Xerostomia

  • Platelet dysfunction – bleeding (avoid ASA/NSAIDs)

  • Stevens-Johnson syndrome

  • Drug interactions: macrolides

  • Potential CNS depression – avoid other CNS depressants

GABA & CNS Depression

GABA: Major side-effect: CNS/Respiratory Depression – coma/death

  • Major inhibitory neurotransmitter in the CNS – reducing neuronal excitability of CNS (pre- and post-synaptic junctions)

  • Target of Benzodiazepines, Barbituates, Anti-convulsants

  • Anxiolytic, Anti-convulsant, Sedative, Amnesia, Euphoria

GABA Agonists: Benzodiazepines, Barbituates, Alcohol, Anticonvulsants (Tegretol/Carbamazepine)

GABA Analogues: bind to Ca/Na channels, act similarly to GABA

  • Pre-gabalin (Lyrica) – Neuropathic pain, generalized anxiety disorders, epilepsy

  • Gabapentin (Neurontin) – Neuropathic pain, Diabetic neuropathy, Anti-convulsant (blocking Na channels)

Flumazenil – GABA receptor antagonist, Tx: Benzodiazepine overdose

NOTE:


Benzodiazepines’ CNS depressant effect is potentiated by: Barbituates, Opioids, Alcohol, Anticonvulsants (other CNS depressants), Cimetidine, Macrolides

**Avoid benzodiazepines in Narrow angle glaucoma!



Neurologic Diseases

Stroke

  1. Definition: Loss of brain fx due to disturbance of blood flow

  2. Types: Hemorrhagic (leakage) or Ischemic (emboli)

  3. Etiologies: Thrombus/Emboli (Ischemic), HTN/various factors (Hemorrhagic)

  4. Symptoms: FASTFace droop, Arm weakness, Speech impaired, Time

  5. Dental Considerations: EMS, Immediate hospitalization

  • Past Hx of Stroke:

    • No elective care for currrent TIAs

    • Delay elective care for 6 months

    • INR: <3.0 for invasive/sx

    • Monitor Vitals/O2 Saturation

    • Use N2O2

    • Limit EPI: 2 carps (>6 months post stroke)

    • Avoid NSAIDs

    • IV heparin – no Sx until another antiocgulant is started

Psychiatric Disorders – Anti-depressant Medications

TCAs:  Serotonin/NE, Side Effects: Avoid respiratory despressants (Benzos, Narcotics) – potentiates respiratory depression, Anti-cholinergic effects (dry mouth/nose, blurry vision)

  • Amitryptiline (Elavil) – Major depression, Migraines, Neuropathic pain

MAOIs: Prevents breakdown of mononamine neurotransmitters; Drug interactions!
***Drug Interactions of TCAs/MAOIs:

  • TCAs/MAOIs + Epinephrine: Limit to 2 carpules

  • TCAs/MAOIs + Flexaril (cyclobenzaprine) -  Respiratory depression

  • TCAs/MAOIs + Respiratory depressants (Benzos, Barbs, Opioids, Alcohol, Anti-convulsants) –  Respiratory depression


SSRIs:  Serotonin by  reuptake synaptic cleft; Interact w/anti-coagulants

  • Celexa, Lexapro, Prozac, Paxil, Zoloft (Most Widely Used category)

SNRIs:  Serotonin/NE

  • Effexor, Cymbalta

Wellbutrin: Atypical antidepressant, added to 1st line drugs

Psychiatric Disorders – Bipolar (affective) Disorder

  1. Definition: Mental disorder characterized by episodes of Manic and Depressive characteristics

  2. Symptoms:

    1. Manic Episodes: period of elevated euphoria, irritability, rapid speech, lack of sleep, and poor decision making

    2. Depressive Episodes: period of sadness, anxiety, guilt, anger, isolation

  3. Treatment:

    1. Medications: Lithium (mood-stabilizer), Anti-convulsants (Valproic Acid, Carbamazepine)

  4. Dental considerations:

    1. Lithium interactions: ASA/NSAIDs, Diuretics, ACE Inhibitors, Narcotics

    2. Avoid ASA/NSAIDs, Narcotics

    3. Med consulation – drug interactions, side effects


Opioids


  1. Effects: Analgesic, Sedation, Respiratory depression, Euphoria

  2. MOA: Bind to ,, opioid receptors – CNS/Peripherally

  • Endogenous opioids: enkephalins, beta endorphins, dynorphins

  1. Semi-synthetic alkaloids: hydrocodone, oxycodone, hydromorphone

  2. Side effects: Nausea, vomiting, drowsiness, respiratory depression, hallucinations, deliruim, brady/tachycardia

  3. Interactions with Benzodiazepines, Barbituates, Anti-convulsants, and Alcohol – CNS/Respiratory Depression

  4. Nalaxone (Narcotics) -  opioid receptor antagonist, Tx: Opioid overdose – IV, IM, Subcutaneous


CNS depressants (Breathing, H.R.): Benzodiazepines, Barbituates, Anti-convulsants (GABA agonists), Alcohol, Opioids, Muscle Relaxants
Muscle Relaxants
Cyclobenzaprine (Flexaril) muscle relaxant

  • Side effects: CNS inhibition (drowsiness/sedation), Anti-cholinergic effects (xerostomia, fatigue, blurred vision), Tachycardia

  • Antagonistic effect: histamine, serotonin, and muscarinic receptors

  • Drug interactions:

    • CNS depressants: Benzodiazepines, barbiturates, anti-convulsants (GABA), alcohol, opioids (BBAAOs) – Potential CNS/Respiratory depression

    • Anti-depressants: TCAs, MAOIs – Potential Serotonin Syndrome or Respiratory depression

    • Psychotropic drugs/Anti-depressants: SSRIs, SNRIs – Potential Serotonin Syndrome



Bisphosphonate-associated Osteonecrosis of the Jaw (BONJ)

AAE Statement: Retrospective studies, case reports/expert opinions only

-MOA: Inhibits Osteoclastic activity, Induces Osteoclast Apoptosis, Inhibits Osteoclastic differentiation; may inhibit angiogenesis

-Indications:



  1. Resorptive Bone Diseases: Osteoporosis, Paget’s Disease, Fibrous Dysplasia

  2. Hypercalcemia associated with certain diseases: Multiple Myeloma, Primary Hyperparathyroidism, Bone metastasis (prostate, breast)

-Drugs: BRADZPD – Boniva, Reclast, Aredia/Actonel, Didronel, Zometa; non-bisphosphonates: Prolia, Denosumab (monoclonal antibody)

-Signs/Symptoms: Mucosal ulceration + exposed bone >8 wks, Pain/swelling, Infection, Altered Sensation (Numbness/Paresthesia)

-Mandible>Maxilla, CTX Test unreliable

-Treatment: Local debridement, Resection, Antibiotics, Hyperbaric Oxygen

-Risk Factors: IV bisphophonates (>1 year or Oral >5 years) - Bioavailibility, Traumatic Dental injury, Nitrogen containing bisphosphonates

**Avoid Exts, Endo Sx, Implants in IV bisphosphonate users

Infective Endocarditis/SBE - PPCC

-Streptococi most common causitive organism, others: staph, enterococci, candida

-Most common complication/cause of death is heart failure (valvular dysfunction)



-Current AHA Guidleines for SBE coverage:

  • Prosthetic cardiac valve

  • Previous IE

  • Cardiac transplant patient who develop cardiac valvulopathy

  • Congenital Heart Disease:

    • Unrepaired CHD

    • Completely repaired within the 1st 6 months

    • Repaired with residual defects at the site or adjacent site

-Dental procedures requiring SBE coverage:

  • Any manipulation of gingival tissues or periapical region

  • Any perforation of oral mucosa, excluding: routine anesthetic injections, radiographs, placement of oral appliences

-Antibiotics (30-60 mins prior, up to 2 hrs post): Amox 2 g (50 mg/kg), Keflex 2 g (50 mg/kg), Clindamycin 600 mg (20 mg/kg), Azithromycin 500 mg (15 mg/kg)

Antibiotic Classes

Bactericidal: PARQ My VehiCle

Penicillins – Beta Lactam Ring – Inhibits the cross-linking of cell wall peptidoglycan (not active against beta-lactamase secreting bacteria), Gram +/-

Aminoglycosides – 30s Ribosomal

Rifampin - RNA

Quinolones – Ciprofloxacin – DNA Gyrase

MetronidazoleInhibits DNA nucleic acid synthesisObligate Anaerobes

Vancomycin

Cephalexin – Beta Lactam – Inhibits cross-linking cell wall peptidoglycan
Bacteriostatic (Protein Synthesis Inhibitors): Country Music Television

Clindamycin (Lincosamide)50s Ribosomal, Gram + Anaerobes, C. dificile associated Pseudomembranous Colitis (nausea, diarrhea, vomiting)

Macrolides (i.e.: Erythromycin, Azithromycin) – 50s Ribosomal

Tetracyclines (i.e.: Minocycline, Doxycycline) – 30s Ribosomal

Medical Condition and related Emergencies

  1. End Stage Renal Disease: 2 HPT – “Stones, Bones, Groans”

  • Lytic lesions (CGCG/Brown’s Tumor HPT), loss lamina dura, Ground glass appearance

  1. Sickle Cell Anemia: Aplastic/Vaso-occlusive crises

  • H.A.D.I.  Pain, Ischemia, Tissue necrosis

  1. Diabetes (Hypoglycemia): Insulin Shock (similar to Vasovagal Syncope)

  • Sweating/Pallor/TachycardiaUncooperative/BeligerentLoss of consciousness/Convulsions/Hypotension

  1. Diabetes (Hyperglycemia): Diabetic Ketoacidosis

  • Hunger, Fruity smelling breath (blood glucose levels)

  1. Addison’s Disease: Adrenal Crisis AVOID SITS

  • Pyschosis, Loss of conscious, Convulsions, Bradycardia, Hypoglycemia, Hypotension, Hypothermia, Circulatory Collapse

  1. Epinephrine overdose: SEE EPI Contraindications Charts

  • Palpitations, Tachycardia  Arrythmias, MI, Stroke

Medical Condition and related Emergencies

  1. Hyperthyroid: Thyroid Storm AVOID SITS

  • Fever, Pyschosis, Tachycardia, Arrythmias, Hyperthermia

  1. Hypothyroid: Myxedematous Coma AVOID SITS/Resp. depress.

  • Bradycardia, Hypothermia, Hypotension, HYPOXIA

  1. Theophylline Toxicity (COPD): AVOID Cipro, Macrolides (CMT)

  • Nausea, Vomiting, Arrythmias, Seizures

  1. Digoxin Toxicity: AVOID EPI

  1. L.A. overdose: CAUTION Chronic Hepatitis, Chronic Kidney Disease

  • Initial: Tremors/convulsions, Later: Loss of consiousness, Respiratory depression, CNS depression, Coma, Death

  1. Met-hemoglobinemia: AVOID Prilocaine, Benzocaine (spray)

  • Met-hemoglobin – metabolite of prilocaine and benzocaine, has Fe+3 instead of Fe+2, Selective affinity for bound O2, decreased O2 to cells = Cyanosis w/o respiratory distress  Respiratory dep/coma/death

Antibiotic coverage for prophylaxis or management of orofacial infections:

  • Uncontrolled Diabetes – Microvascular disease (infection/delayed healing)

  • End Stage Renal Disease – Leukopenia, consult physician

  • Autoimmune disorders (immunosuppressant therapies):

    • Crohn’s disease/Ulcerative Colitis

    • Rheumatoid Arthritis

    • SLE

    • MS

  • HIV: Stage 3: AIDS – CD4+ <200 cells/L (post tx/sx)

  • Organ/Bone Marrow Transplantation – Leukopenia, immunosup., consult physician

  • Sickle Cell Anemia – Aggressive management of infections (vasoclusion)

  • Aplastic Anemia – Med consult, Pancytopenia

  • WBC tumors: Leukemia, Lymphomas, MM – consult physician

    • WBC < 2000 cells/L

    • Neutrophil count < 500 cells/L

    • 6 months post splenectomy (lymphoma patients)

  • Chemotherapy – Bone marrow suppression, WBCs < 1000 cells/L, PMNs <500

  • H&N Radiation – Prevention of Osteonecrosis (Sx only, <6000 cGy)

Rhinosinusitis (Kretzschmar)

Definition:



  • Inflammation and infection of the mucous membranes of the nasal/paranasal sinuses (maxillary, frontal, ethmoid, sphenoid), Tissue edema, Non-patent ostia

Types:

  • Acute <4 wks, Subacute 4-12 wks, Recurrent Acute 4+/1 yr, Chronic >12 wks

Etiology:

  • Viral Infection, may progress to Bacterial infection, typically after 7-10 days

Symptoms:

  • Major: Facial pain, Facial pressure, Congestion, Nasal obstruction, Fever

  • Minor: Headache, Dental pain, Cough, Ear pain

Dental Findings:

  • Pain on palpation of Infraorbital region, Pain on percussion multiple Max. posterior teeth, Diffuse lingering pain in Max posterior, Cloudy sinus

Treatment:

  • Decongestants (Systemic: Pseudophedrine 30 mg q6h, Nasal: Oxymetazoline 0.05%, Phenylephrine 0.125-1.0%, Neosynephrine 0.5%), Amoxicillin 500 mg q6h 10 d or Clindamycin 300 mg q6h, Augmentin 500 mg q12h 14 days (if no response to Amox)

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