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429 Cards in this Set

  • Front
  • Back
What is the preg category of benzocaine?
C
When is Benzocaine contraindicated?
pregnant patients, allergic to esters, methemoglobinemia
where are amide local anesthetics metabolized?
liver
When is Prilocaine and Articaine contraindicated?
patients with methemoglobinemia, ASA III/IV hypoxic state COPD, CKD, moderate to severe anemia/kidney disease, MS or other neuromuscular disorders
What is the pregnancy cat of Marcaine?
C
What is the allergen associated with articaine?
bisulfite/metabisulfate allergy
What is the pregnancy category for Articaine?
C
What is the ideal anesthetic for the hypertensive pregnant patient?
Citanest Plain
What are the LA alerts with liver disease?
minimal LA should be used since toxicity can occur, SIMPLE dentistry over multiple visits
How many MAX carpules of LA for medically comprimised patient?
2!!
What should be avoided in conjunction with the following:
Pheochromocytoma, MAO-I/tricyclic antidepressants, patients on anti-psychotics, PTU/Tapazole/Methimazole, ASA III-IV status, significant coronary artery disease, narrow angle glaucoma, Digoxin, Theophylline
LAs with Epinephrine
two stages of LA overdose?
hyperactive, hypoactive
How do you deal with a CONSCIOUS patient with LA overdose?
An UNCONSCIOUS PATIENT?
Conscious:
semi-seated, reassure pt, tell to hyperventilate

Unconscious:
horizontal position, assess ABCs, Activate EMS, Give Diazepam 10 mg IV Slowly if needed
how long should any pain medication be perscribed?
2-3 days
How long is Aspirins effect on platelets?
permanent, lasts for 10-14 days
When must aspirin be stopped for minor dental procedures? major dental procedures?
no need to stop for minor, 7 days pre-op for major surgery, restart 1-2 days post op
What is the pregnancy category for aspirin?
C/D after 30 weeks
When should aspirin be used in dentistry?
never
What is the preg cat for Ibuprofin? dose with liver and kidney disease?
C/D, AVOID in kidney and liver disease
What is the normal dose and max dose for ibuprofin?
200-400 mg q4-6h, max: 1200 mg/day
Pregnancy cat for naproxen? Liver and Kidney dose?
C/D, AVOID in liver and kidney disease
Normal dose, max dose for Naproxen?
250-500 PO q12h, max: 1500 mg/day
Preg Cat for Celebrex? Dose with Liver and Kidney disease?
C/D, AVOID in liver and kidney disease
What allergy would contraindicate the use of Celebrex?
Sulfa-antimicrobial allergy
toxic metabolite of Tylenol? when is tylenol contraindicated?
NAPQI, With alcohol, or alcohol related liver disease
What is the pregnancy cat for APAP? Max dose? Dose with kidney and liver disease
B, Max dose: 4g/day

liver: increase interval (q6 or q8), liver max dose: < 2 g
kidney:increase interval with S. Cr >2.2 and dialysis
What affect will combining APAP with coumadin have?
Can increase INR within 18-48 hours
Use of opiods with liver and kidney disease? drugs to use, drugs to avoid?
In general, lower dose and prolong interval. AVOID meperidine, propoxyphene, pentazocine.

USE: hydromorphone (Diluadid) or Fentanyl
Opiods that are okay to use during pregnancy
Oxycodone (percocet), fentanyl, hydromorphone, meperidine, morphine sulphate
What is the most prescribed strength of Tylenol with Codeine?
Tylenol #3: 30 mg codeine, and 300 mg APAP
Percocet is APAP and what? Vicodin is APAP and what?
Percocet: Oxycodone
Vicodin: Hydrocodone
which opiod analgesic is NOT a controlled substance?
Tramadol (Ultram)
What enzyme is required to activate the prodrug Tramadol?
CYP2D6
Drugs that affect 2D6?
SSRI or tricyclics for depression
What analgesics can be used with kidney and liver disease?
reg strength tylenol, dose modified codeine and tylenol, dose modified vicodin or percocet, hydromorphone, fentanyl
When using the same antibiotic for premedication, how long should the interval be between appointments?
no less than 7 days
how long is an early infection symptomatic? late infection?
early infection (less than 3 days), late infection (more than 3 days)
What is the antibiotic of choice for early infection?
pen VK or clindamycin with pen allergy
What is the preferred antibiotic for an early infection in an immune compromised patient?
Amoxicillin
what is the preferred antibiotic for use in late infections? alternates?

what about with immune comprimised patients?
clindamycin (1st choice)
alternates: azithromycin, flagyl (pen VK and metronidazole)

immune comprimised: amox and metronidazole
should bacteriocidal and bacteriostatic antibiotics be used together?
NO, always have at least a 6h interval
what is the weight cut off for using a smaller dose of antibiotics?
< 140 lbs use smaller dose
Pen VK: cidal or static? Preg category? Liver and Kidney?
cidal, preg cat B, increase interval with kidney, no dose adjustment in liver
pen VK dose for infection management:

pre-med prophy:
dose: 250-500 mg qid for 5 days

pre-med: not used
Amoxicillin: preg cat, cidal or static? dose? dose for acute abscess?

pre med dose?
preg cat B, cidal

dose: 250-500 mg tid
abscess: 6 500mg capsules TWICE in 8 hours

pre med: 2g PO 1 hr before procedure
Amox dose with liver and kidney disease?
kidney: interval adjustment (q 12h)
liver: no dose adjustment (same as Pen VK)
side effects of Augmentin:

DDIs
side effects: very easily washes out intestinal flora

DDIs: increases effectiveness of coumadin/warfarin
when should Ampicillin be used for premed prophylaxis?

premed dose?
in patients unable to take oral medications

2 g IV/IM 30 min prior to tx
Cephalosporin preg cat:

cidal or static:
B, cidal
Cephalosporins should be avoided in patients with a severe allergy to what?
penicillins
What are the pre med drugs of choice for patients with joint prosthesis? dose?
keflex or duricef (cephalosporins)

2g PO 1 hr before tx
drug of choice for pre-med prophy for patient with joint prosthesis unable to take oral medication?
cefazolin or ceftriaxone (1g IV/IM 30 min prior)
Clindamycin, cidal or static?
at low doses (150/300mg) it is static

at high doses (600mg PO for premed): it is cidal

at low IV/IM doses, it is cidal too
Cephalosporin dose for infection mgmt:

with kidney and liver disease?
keflex: 250-1000 mg qid

duricef: 1-2g/day in TWO doses (bid)


increase interval for both
What is the premed antibiotic of choice for patients who are pen allergic and cannot take oral medications?
cefazolin or ceftriaxone (1g IV/IM 30 min prior)
clindamycin pregnancy cat:

dose:

premed dose:
B,

150-450 qid (static dose)

premed: 600 mg PO 1 h prior or
600 mg IV 30 min prior (cidal doses)
what are the macrolides? which is the safest?
azithromycin, clarithromycin, erythromycin

safest: azithro
What drug would be used in SBE prophylaxis in pen allergic patients?
Azithromycin or clarithro
What are the only antibiotics contraindicated with pregancy?
Clarithromycin and tetracyclines
What antibiotic affects CYP3A4 and has many DDIs for that reason?
Clarithromycin
Azithro dose with kidney and liver:

Clarithro dose with kidney and liver:
Azithro:
liver: no dose mod with mild-mod hepatits, AVOID in severe liver disease
kidney: no dose adjustment with kidney disease

Clarithro: opposite.
Kidney: AVOID
Liver: no dose change
Azithro dosing:

premed dose:
azithro dosing:
5 day:
250 bid or 500 HS on first day, then 250 mg/day for 5 days

3 day: 500 mg/day for 3 days

premed: 500 mg PO 1 hr prior (same with clarithro)
Metronidazole preg cat:

frequent oral side effects:
B

side effects: dry mouth and metallic taste
drug of choice for pseudomembranous colitis?
metronidazole
what should absolutely be avoided in conjunction with metronidazole?
Alcohol (will result in extreme nausea and vomiting)

avoid till 48 hrs after last dose
metronidazole dose?

kidney and liver dose?
250 q6h or 500 q8h

increase interval with both kidney and liver diseases
how long is flagyl prescribed for the treament of pseudomembranous colitis?
10-14 days
if metronidazole is ineffective after trying to treat pseudomembranous colitis for the 2nd time, what drug should be prescribed?
vancomycin
Metronidazole is a potent inhibitor of what enzyme? causes accumulation of what drug?
CYP2C9, causes accumulation of Dilantin
Tetracycline and doxicyclin dose adjustment with kidney and liver disease?
doxy: no adjustment

tetracyclin: avoid in liver, dose adjust in kidney
Vancomycin preg cat:
C
Tetracycline: cidal or static?
static
when is vancomycin used?
MRSA and pseudomembranous colitis
What durg would be used to treat pseudomembranous colitis in the patient with alcoholic liver disease?
vancomycin
what affect do broad spectrum antibiotics have on coumadin?
wipe out intestinal flora that normally synthesize vit K, therfore patients on coumadin may experience excessive bleeding

always suggest yogurt or probiotics
vancomycin dose in liver and kidney disease?
liver: no dose adjustment
kidney: avoid
drug of choice for treating early oral infection in patient on bactrim OD for PCP Prophylaxis?
Azithromyxin OD with bactrim because they are both cidal.
What are the 14 conditions that require pre med prophylaxis?
1. prosthetic heart valves, 2. past hx of infective endocarditis, 3. unrepaired cyanotic heart condition, 4. completely repaired congenital heart condition after 6 months, 5. repaired heart condition with residual defect near prosthetic patch, 6. cardiac transplant patients who develope valvulopathy, 7. systemic intracranial hydrocephalic shunt, 8. hemodialysis shunt, 9. peritoneal dialysis with indwelling catheter, 10. extra-cardiac synthetic graft material, 11. cancer drugs through infuse port or hickman catheter, 12. cirrhosis with ascites, 13. ANC below 1500, 14. prosthetic joints
What stress mgmt can be used in ASA III/IV patients? What LAs?
O2 + N20 can be used (NO BENZOS)

LAs without epi should be used (carbocaine and citanest plain)
when using benzodiazepines, what special instructions should the patient be given?
only to be used if patient has someone to escort them
in what patients should benzodiazepines be avoided?
pregnant, elderly, obese, patients on CNS drugs or H2 blockers
Does platelet count affect primary or secondary hemostasis?
primary
What test shows the functioning capacity of platelets?
bleeding time
What is the ave life span for normal RBCs?
120 days
what CBC value is used to measure the extent of anemia?
hematocrit
What does this CBC value indicate:

MCV below normal?
Microcytic cells: seen in iron deficiency anemia and thallasemia
What does this CBC value indicate:

MCV above normal?
macrocytic cells:

seen in problems with DNA synthesis such as pernicious anemia/B12/Folic acid deficiency
HIV/AIDS meds, cytotoxic drugs
What CBC value helps differentiate between hypochromic and normochromic RBCs?
MCHC (mean corpuscular hemoglobin concentration)

MCHC is decreased in hypochromic microcytic anemias

MCHC is normal in macrocytic anemias
What CBC value helps differentiate between iron deficiency anemia and thalasemia?
RDW (red cell distribution width)

It is increased in iron deficiency anemia and normal in thalasemia
What conditions would be suspected if the CBC showed a decrease in Hb and hematocrit but normal MCV and MCHC?
decreased RBC synthesis:

SLE, RA, and Chronic Renal Failure
What conditions would be suspected if the CBC showed a decrease in Hb and hematocrit with a decrease in MCV and MCHC?
problems in Hb synthesis:

Iron Def anemia or thallasemia

differentiated by looking at the RDW (increased for iron def and normal for thalasemia)
What conditions would be suspected if the CBC showed a decrease in Hb and hematocrit with an increase in MCV and normal MCHC?
problems with DNA synthesis:

Pernicious anemia, B12/Folic acid def., cytotoxic drugs, hiv meds, dilantin
What are the classifications of anemia based on percentage drop of Hb?
Mild (25% drop of Hb)
Moderate (25-50% drop)
Severe anemia (>50% decline in Hb)
What are the guidelines for treating the Anemic patient?

Stress mgmt:
Analgesics:
Anesthetics:
Antibiotics:
Stress mgmt: O2 and N20 (no benzos, they depress resp. center)

Analgesics: tylenol, codeine/oxycodone/hydrocodone
(Avoid codeine sulphate in G6PD anemia)

Anesthetics: mild anemia (xylo max 2 carp) mod (carbocaine or marcaine 1:200,000 epi), sev (defer Rx) (AVOID 4% LAs!)

Antibiotics: most anything
what does an increased WBC with increased neutrophils indicate?
acute bacterial infection
what does an increased WBC with increased lymphocytes indicate?
viral infection
what does an increased WBC with increased monocytes indicate?
chronic bacterial infection (SBE or mycobacterium TB)
or acute exasterbation of chronic inflammation (SLE, RA)
what does an increased WBC with increased eosiniphils indicate?
allergy, parasite or hodgkin's lymphoma
what does an increased WBC with increased basophils indicate?
chronic myelocytic leukemia or polycythemia
How do you calculate the ANC?
ANC = WBC count x ((# of neutrophils + # of bands)/100)
what is a normal ANC?
1500-7200
what are the ANC categories?
mild neutropenia: 1000-1500
mod neutropenia: 500-1000
severe neutropenia: < 500
what are the guidelines for treating mild neutropenic patients?
mild: can have maj and minor dentistry, oral cidal or static antibiotics ok, only premed for major procedures, give antibiotics for 3-5 days following major procedure, have pt use non-alcoholic mouth rinse prior to treatment
what are the guidelines for treating moderate neutropenic patients?
can have maj and minor dentistry, oral cidal or static antibiotics ok, premed for ALL major and minor procedures, give antibiotics for 3-5 days following major procedure, have pt use non-alcoholic mouth rinse prior to treatment
what are the guidelines for treating severe neutropenic patients?
only palliative tx for acute dental problems: I & D, pain meds, antibiotics

do not give oral antibiotics, IV/IM only
will there be pus formation in an infection in a pt with a neutrophil count under 500?
no, or very minimal

fever is usually only symptom
what condition is associated with an increased number of circulating RBCs? what are causative factors?
polycythemia.

due to Hypoxia, COPD, smoking, erythropoietin producing tumors
what is the name for the condition where there is increased deposition of iron in the tissues?
hemochromatosis
What are the two classes of antifungals?
Polyenes and Azoles
What are the two Polyene antifungal classifications?
Nystatin and Amphotericin B
What are the two Azole classifications?
Imidazole and Triazoles
What class of antifungals inhibits CYP450 enzyme? what class of drugs should be avoided with this class of antifungals?
Azoles, benzodiazapines should be avoided
What are the Imidazole azoles? the Triazole azole antifungals?
Imidazoles (older): ketoconazole and clotrimazole

Triazoles(newer): Fluconazole and Itraconazole
Which class of antifungals does NOT have DDIs?
Topical and oral polyenes
What antifungal is the drug of choice for patients experiencing xerostomia?
Nystatin suspension
How long are antifungals typically prescribed?
14 days
What important instruction must be given when treating denture wearers for oral candidiasis?
They MUST also treat their dentures or RPDs in a nystatin solution.
What is the pregnancy category for Nystatin?
B
How is Amphotericin B metabolized? What are it's DDIs?
Cleared by kidneys, avoid nephrotoxic drugs/corticosteroids
What are the DDIs with Clotrimazole?
inhibitor of CYP450 (avoid benzos)
In general, where are azole antifungals metabolized?
Liver, avoid alcohol use and avoid with liver disease
What antifungal needs an acidic pH for absorbtion? (avoid H2 blockers, antacids, vitamin supplements)
Ketoconazole
What class of antifungals is OK for pregnant women to take?
Polyenes
What is the antifungal of choice for blastomycosis, asperigillus infection, histoplasmosis, onychomycosis?

IV form used for treatment in life-threatening conditions?
Itraconazole
In general, where are antivirals cleared? Dose modification for kidney/liver disease?
Antivirals are cleared in the kidney (decrease dose).

No dose adjustment in liver disease
Acyclovir should be avoided with what drugs? (there are 6)
1. amphotericin B
2. Bactrim
3. Aspirin
4. NSAIDS
5. Zidovudine (AZT/Retrovir)
6. Prograf
What should be supplemented when treating HSV breakouts with acyclovir ointment?
should be used in conjunction with acyclovir capsules
typically, how many times a day is acyclovir taken? for how many days?
taken 5 times a day for either 5 or 14 days.
Which antiviral is a prodrug requiring the 2D6 enzyme? What drugs should be avoided with the perscription of this antiviral?
Valacyclovir.

Should be avoided with SSRIs!
SSRIs are inhibitors of what enzyme?
What does this enzyme do?
2D6, this enzyme converts prodrugs to their active form (Ex. valacyclovir, codeine, ultram, etc.)
What lab tests should be obtained to assess Anemia/Immunity/immediate bleeding status?
CBC with platelets and WBC diff.
What lab tests should be obtained to assess patients on Coumadin/Heparin/delayed type of bleeding status?
PT/INR (Coumadin) and PTT (Heparin)
What lab tests should be obtained to assess liver status?
LFTs, hepatic serology
What lab tests should be obtained to assess renal status?
GFR/BUN/S. Cr.
What lab tests should be obtained to assess Diabetes status?
FBS, PPBS, and HbA1C
What lab tests should be obtained to assess HIV/AIDS status?
CD4 count; viral load; CBC; LFTs; Serum Creatinine
What are the ideal lab values for a controlled diabetic patient?
FBS < 125 mg/dl
PPBS <140 mg/dl
HbA1C < 7% (N= 4-6%)
What are the Systolic and Diastolic ranges for normal, pre-HTN, stage I, II, and III?
Normal: Sys: < 120 Dia: <80
Pre-HTN: 120-139; 80-89
Stage I: 140-159; 90-99
Stage II: > 160; >100
Stage III: > 180; >110
For diabetics, how does the HTN classification differ?
Normal is < 130/80, there is no preHTN, starts with stage I being 130-149/80-89
What does Digoxin treat? What AAAs can be given with it?
Rx: CHF and AF

Anesthetic: carbocaine
Analgesics: Tylenol, Tylenol #3, vicodin, percocet
Antibiotics: pen, cephalosporins, clinda, azythro
What drugs (AAAs) should be avoided with Digoxin?
Anesthetics: Avoid epi containing
Analgesics: avoid aspirin and NSAIDS
Antibiotics: avoid macrolides and tetracyclines (except azithro is fine)
What is Theophylline used to treat? What are the AAAs that should be avoided?
Used to treat mod-severe asthma.
Avoid:
Anesthetics: LAs with epi
Analgesics: Aspirin or NSAIDS (if known to cause an allergy)
Antibiotics: ALL macrolides (penicillin if pt allergic)
What recreational drug will potentiate LAs with epi?
Cocaine
patient should be drug free for how long before they sit in dental chair?
24 hours
what considerations should be made with a patient with a dental infection that is on oral contraceptives?
Antibiotics will deactivate the OCs, make sure patient takes EXTRA precaution until the end of the next cycle if prescribed oral antibiotics
Medications for what 3 conditions should always be brought by patient to the dental office in case of emergency
asthma meds, angina meds, hypoglycemia medications
What patients is an AM appointment a must?
Myasthenia gravis and steroid replacement
What should always be determined before treating a diabetic patient?
If patient has a full stomach! Make sure they do
What stress mgmt can be used for ASA I and II patients? ASA III Patients?
ASA I/II: Benzos, O2 + N20
ASA III/IV: O2 + N2O
(except avoid 02 + N20 in COPD patient)
What are the elements of primary hemostasis? symptoms of a problem with primary hemostasis?
Elements: Vascular response, platelet number and function, VWF

Symptoms: oozing after extraction for 24 hours+, petechia, small bruises, positive HO mucous membrane bleeding
What are the elements of secondary hemostasis? What are the symptoms of a problem with secondary hemostasis?
Elements: clotting factors interacting to form fibrin clot

Symtoms: deep tissue bleeding 4-10 days post op, large bruises (hematomas), hemarthrosis, on coumadin or warfarin
What are the functions of VWD?
enhances cohesiveness of platelets ADN helps stabilize and transport factor VIII
Where are all clotting factors (aside from VIII) made? Where is clotting factor VIII and VWF made?
the liver; the endothelial cells of blood vessels
What are the vit K dependent clotting factors?

Low levels of these factors can prolong what?
II, VII, IX, and X;

the PTT and PT/INR
What is the leading cause of clotting factor deficiency?
alcoholic cirrhosis
Will the PT/INR be prolonged in a cirrhotic patient?
Not always. Factor activity must drop by > 75% to have an affect on PT/INR
What labs should be requested prior to probing a cirrhotic patient?
PT/INR and CBC with platelets
T or F, thrombocytopenia can be seen in cirrhotic patients?
True. platelets are produced partly in the liver
What tests should be assessed to evaluate primary hemostasis? secondary hemostasis?
primary: BT
secondary: PTT & PT/INR
Platelet counts:
Average?
Thrombocytopenia?
Spontaneous bleeding?
Req. for Routing Dental treatment?
Req. for outpatient OS/Perio surgery?
Req. for Major dental procedures done in OR?
Normal: (150k-400k)
thrombocytopenia (<150k)
spontaneous bleeding: <20k
routine dental treatment: >50k
OS/Perio: >75k
Major/OR: >100k
What drugs are often used to treat ITP?
steroids, ALWAYS CHECK FOR RULE OF 2s, oral candidiasis
What drug is used to elevate VWF level in the blood and stimulate platelet release?
DDAVP
What drugs affect platelets? For how long?
Aspirin, Plavix, Persanthin, and Ticlid:
All irreversible and permenantly affect platelys (7 days)

NSAIDS: affect lasts 24 hrs
When should Aspirin be stopped before surgery/restarted?

When should NSAIDs be stopped before surgery/restarted?
Always consult MD.

Asprin - stopped 7 days prior, started 1-2 days post op

NSAIDs - stoped 24 hrs prior, restart evening of or next day (whenever bleeding stops)
When do you stop Asprin intake for an upcoming amalgam/composit, cleaning, deep scaling?
no need to stop any anti-thrombosis drugs for these treatments
What labs are prolonged with VWD?
Always prolonged BT.

SOMETIMES: prolonged PTT (in severe cases only)
What is the most common inherited bleeding disorder?
VWD
T or F, VWD patients can present with problems associated with both primary and secondary hemostasis.
T
What type of VWD is associated with thrombocytopenia?
VWD 2B
What tests are used to diagnose VWD?
RIPA tet and Ristocetin co-factor activity test
How will the PTT and PT/INR appear in a patient with VWD?
The PT/INR will be normal.

The PTT may be prolonged in a patient with severely depressed activity of factor VIII
How do you treat VWD types 1 and 2A?

types 2B and 3?
Types 1 and 2A:DDAVP;

Types 2B and 3:Factor concentrate
Coumadin/Warfarin affects the synthesis of what?
vit K dependent clotting factors (II, VII, IX, X)
Does coumadin cause prolongation of PTT or PT/INR?

Which is monitored?
both, but only necessary to monitor PT/INR
What can be given to reverse the effect of coumadin?
Large dose Vit K or FFP
What is the theraputic range for PT/INR for patients on coumadin?

What is the range for patients with a high risk for thrombosis?
theraputic range 2.0-3.0

high risk: 3.0-4.5 or greater
What are the DDIs with patients on coumadin?
Antibiotics that affect intestinal flora:
Amox + Clavulanic acid
Cephalexin, Cephadroxyl
Doxycyclin
Metronidazole
SAFE: Pen and Clinda

Analgesics:
Avoid extra-strength tylenol (can cause 4-9x increase in INR)
(use reg strength tylenol, tyl #3, vicodin, percocet)

Antifungals:
Avoid SYSTEMIC antifungals:
Fluconazole, Ketoconazole
(use topical nystatin)
What blood test measures the intrinsic clotting pathway?

What anti-coagulants affect this pathway?
PTT.

IV heparin and coumadin
T or F: Amalgams, composites, prophys, and deep scaling can be done without coumadin stoppage?
T
Is it okay to interupt coumadin in a patient being held in the theraputic range for major surgery?

What abour in the higher INR range?
Theraputic: MD will OK coumadin stoppage

Higher INR: Thinning never interupted. Coumadin-Heparin Bridge with LMWH or IV Heparin
Coumadin is metabolized by what liver enzyme?
3A4
what is THE drug for any acute thromboembolic state?
IV Heparin
How does a heparin bridge work?
with IV heparin:
coumadin stopped, IV hep started with INR drops below 2, PT/INR should reach around 1.0.

IV Heparin stopped and surgery takes place 6 hrs later.

Once adequate hemostasis occurs, IV heparin restarted, coumadin started evening of or next day

Takes 7 days
what are the DDIs for heparin?

what is the heparin antidote?
Aspirin, NSAIDs, Cephalosporins, Tetracyclines, Antihistamines

will all increase heparin action

antidote: protamine sulfate
what are the benefits to using LMWH instead of IV heparin when bridging?
no hospitalization needed, no need to monitor PTT
how long after coumadin is taken is it most active? why is this important for scheduling appointments?
peaks between 60-90 minutes after taken PO.

If taken in the morning, schedule a later appt. If taken in the evening, schedule an earlier appointment
in a patient taking coumadin, when must the PT/INR be assessed prior to surgery?
when the patient is maintained usually above the theraputic range (>3-4.5)
How should anesthesia be achieved in patients on coumadin?
avoid regional block injections, use intra-papillary and intra-ligamentary injections (especially in patients kept above theraputic range)
what are Amicar and Cyklokapron used for?
they are hemostatic mouth rinses
past history of what symptoms would be a red flag to watch out for when perscribing Amicar for hemostasis?
moderate to severe headaches, acute visual problems, TIAs, CVAs/strokes, blood clots
What are the clotting factors that are deficient in hemophilia A and B?
A: Factor VIII
B: Factor XI
What are the levels of severity for hemophilia?
mild: factor is 5-30% of normal
mod: factor is 1-5% normal
severe: factor less than 1% normal
How is Hemophilia A treated? B treated?
Both treated with specific factor replacement

Mild A can be treated with DDAVP, not B though. DDAVP
What must a mod/severe hemophilic patient take prior to ANY dental treatment including probing and local anesthesia?
specific factor replacement
one unit causes 2% rise in factor VIII and 1% rise in factor IX

50% factor activity is a MUST for block anesthesia
what are the benefits to using pradaxa as opposed to coumadin?
unlike coumadin, predaxa has no dietary restrictions, safer than coumadin, ONLY DRUG to decrease stroke mortality in AF, no blood test monitoring, NO DDIs
What are the DDIs with pradaxa?
No DDIs, do not prescribe asprin or NSAIDs with pradaxa!
Can pradaxa be bridged with heparin in a patient at high risk for thrombosis before major dental surgery?
yes.
What are Dabigatran (Pradaxa) and Rivaroxaban used to treat?

what are the main differences between them as far as dosing and DDIs?
They are both used for stroke prevention.

Pradaxa is bid and has NO DDIs
Rivaraxaban is once daily and has DDIs with CYP450 inhibitors (macrolides, st johns wart, azoles, dilantin, etc) AND with P-gp: a drug transporter that helps with exretion
What is the standard premed regimen for a normal, non-pen allergic adult? child?
amox 2g po 1 hr
child: 50 mg/kg PO 1 hr prior
What is the premed regimen for non-pen allergic patients unable to take oral medication?
Either:
Ampicillin
adult: 2 g IV/IM 30 min prior
child: 50 mg/kg IV/IM 30 min prior

Cefazolin or Ceftriaxone
adult: 1 g IM/IV 30 min
child: 50 mg/kg IV/IM 30 min
what is the premed regimen for the pen allergic patient?
clindamycin
adult: 600 mg PO 1 hr
child: 20 mg/kg PO 1 h

Cephalexin**:
adults: 2 g PO 1 hr
child: 50 mg/kg PO 1 hr

Azithromycin or Clarithro:
adults: 500 mg po 1 hr
child: 15 mg/kg po 1 hr

**avoid cephalosporins in immediate type hypersensitivity to Pen
What is the premed regimen for pen allergic patients unable to take oral medication?
Cefazole or Ceftriaxone** (avoid in severe allergy:
1g IV/IM 30 min
child: 50 mg/kg IV/IM 30 min

or Systemic Clindamycin:
adult: 600 mg IV 30 minutes before the procedure
children: 20 mg/kg IV 30 min before the procedure
Which needs premed prophy, bioprosthetic or mechanical heart valves?
both prior to invasive dentistry
What are 3 sources of bioprosthetic heart valves?

which require blood thinning with coumadin? which require daily aspirin following coumadin?
pig, bovine, human

all require coumadin for 1st 3-6 mo
pig and bovine will require aspirin for life
Would it be okay to perform routine dentistry in a patient 4 months after a valve replacement with a human bioprosthetic valve?
No, best to defer during uninterrupted anticoag period (first 3-6 months). only needed treatments can be performed, and the MD may provide a heparin bridge
which type of heart valve replacement will require heparin bridge for minor and major surgery?
mechanical, not bioprosthetic
What are the 2 types of stents? which requires a longer period of anticoagulation? which requires pre med?
bare-metal:
min 1 mo anticoag
no premed req

drug eluting:
min 12 mo anticoag
no premed req
What are the 2 types of prosthetic valves? which requires what type of anticoagulation? which requires pre med?
bioprosthetic:
coumadin 1st 3-6 mo followed by aspirin (pig, bovine) or nothing (human)
pre med req

mechanical:
life long coumadin blood thinning
pre-med req
what oral antibiotics are good for joint prosthesis prophylaxis?
cephalexin, Clinda and azithro
what is the premedication protocol for seeing a patient in successive appointments?
when using same antibiotic, keep apt at least 7 days apart

when needing to see patient more frequently, switch from amox to azithro (day 3) to clinda (day 6) and repeat
What is the protocol for premedicating AND managing and infection?
you can premed and mgmt with the same antibiotic (must be sure to not use that antibiotic as premed during apts in the next 2-3 weeks)

OR

You can manage infection with antibiotic different from what was used as premed (no need to change up pre med for subsequent visits)
what anesthetics can be used for mild hypertension? what about moderate hypertension? severe?
mild controlled (asa I or II): xylo with epi
mild: marcaine or citanest forte
moderate: carbocaine
severe: defer
what condition has:

Clinical features: S/S last seconds to minutes without loss of consciousness, paresthesias, blurred vision, slurred speech, disorientation

Vital signs: pulse rapid and bounding, increased BP

Tx: upright position, reassure, monitor viral signs, AVOID O2
T.I.A.
what are the 2 kinds of CVAs? what are the differences?
1. Ischemia/Infarction CVA: Onset is gradual and loss of consciousness is rare

2. CVA due to intracranial hemorrhage: onset is dramatic and unconsciousness is common
What are the differences in the clinical features of a TIA vs a CVA?
with a TIA, the symptoms last seconds and with a CVA there are progressive neurological s/s
what are the dental guidelines with Cerebral circulatory problems (TIAs, CVAs)?
Acute CVA needing prolonged hospitalization: delay dentistry for 6 mo

recovery after over night hospitalization (mini stroke or recurrent TIAs): defer tx for 3 mo

avoid epi 1st 6 mo of dental visits

follow anticoag guidelines (stop aspirin/plavix 7-10 days prior to major surgery)
what condition? tx?

chest discomfort lasts for 2-5 min, max 10-15

anxiety, sweating, chest tightness, closed fist, rapid bounding pulse, increased BP
Angina Pectoris

tx: upright position
NTG SL 0.3 mg/tab, max 3 tabs
what are the dental guidelines for stable angina? for unstable angina?
stable: have patient bring NTG, use max 2 carp xylo with epi

unstable:
avoid epi
use NTG for stress mgmt if needed
treat in a semi sitting position
A patient on either Isordil or NTG patch indicates what?
ASA (III) status, unstable angina, AVOID EPI and use stress mgmt (can use Isordil which is long acting NTG for stress mgmt)
what is the conditon? treatment?

"crushing pain" lasts for more than 15 minutes, usually hours, acute distress, cold moist skin, nausea, vomiting, abdominal bloating, pulse rapid and thready with decreased BP
myocardial infarction

tx: MONA
morphine (given 2-5 mg q5-15 until pain gone)
Oxygen (4-6 L/min)
NTG 0.3 mg STAT as long as SB above 115mmHg
Aspirin (162/325mg under tongue/chew/swallow, avoid enteric coated)
what are the dental guidelines fore MI patient?

What if patient is on digoxin?
dental tx delayed for 6 months following massive MI, 3 mo for minor MI

avoid epi for 1st 6 mo of dental visits, if okay, epi can be used (md consult)

*digoxin: avoid epi, marcrolides, tetracyclines, aspirin, NSAIDs
How is kidney function related to serum creatinine levels?
serum creatinine levels rise with declining kidney function
what is the GFR in a patient with chronic renal disease?
<60 mL/min/1.73 m2 for 3 months
what are the hematological changes associated with kidney disease (and their significance for dentistry)?
anemia (decreased erythropoietin production)
increased potassium (avoid pen VK)
increased phosphate (no vit D to grab calcium from gut, grabs calcium from bone, raryfication or brown tumors)
decreased calcium (vit D deficient)
decreased magnesium (skeletal muscle soarness, TMJ dysfunction)
is premed required in a patient who received a kidney transplant?
It depends on the hemodialysis access used by the patient pre surgery. these are usually left in.

IV catheter, AV synthetic grapht: must premed

AV fistula: does not require premed, but consult with MD
what is an important consideration when performing exam on patient with AV fistula?
dont take BP on that arm
Is premedication needed for a patient who undergoes peritoneal dialysis?
not required unless an indwelling catheter is present
What are the AAAs with kidney disease? Stress mgmt?
LAs:
-S Cr. <2.mg/dL - lido max 2 carp
-S Cr. >2 mg/dL - carbocaine
AVOID 4% due to hypoxia (low erythropoietin)

Analgesics:
avoid aspirin, NSAIDS, ES tylenol, propoxyphene, meperidine

Can give:
S Cr <2mg/dl - reg strength tylenol or tylenol + codeine, vicodin or percocet, normal dose
S Cr >2 mg/dl - increase interval

antibiotics:
Azythro safe, clinda safe, doxy safe
penicillins safe, increase interval with s cr >2mg/dl

cephalosporins: 50% dose reduction

CAN use benzos if patient is on erythropoietin replacement therapy
What drugs should be avoided when a patient experiences pain in the calves upon walking?
LAs containing epi/ epi cords

patient has problem with peripheral circulation/intermittent claudication
Diuretics, beta blockers, angiotensin coverting enzyme, angiotensin II receptor blockers, and calcium channel blockers are used to treat what condition?
hypertention
What anesthetics can be used with HTN?
ASA I or II with NO end organ problems: Xylo with epi, citaneste forte or marcaine.

Moderate HTN: carbocaine

Severe: defer
what are the dental guidelines for treating a patient with arrythmias?
consult with MD to understand nature or arrythmia, stress mgmt used, shorter appointments, avoid epi
What special guidelines should be followed with patients with pace makers?
no electronic pulp testing and keep any other electrical devices out of arms reach
what are the two types of asthma and their basic characteristics
intrinsic - more common in childhood and associated with allergy, SELDOM progresses to COPD

extrinsic - usually adult onset, associated with pulmonary infection, OFTEN progresses to COPD
what is theophylline used to treat? what should be avoided with this drug?
complex asthma, avoid epi/macrolides/caffeine/chocolate/quinolones/cimetidine
what class of drugs are the immediate-relief medications for asthma attacks?
B2 agonist bronchodilators (metaproternol, albuterol, etc)
what are the important dental guidelines for treating asthma patients?
1. question patient about triggers
2. provide stress mgmt (95% of attacks are stress related)
3. use puff of inhaler as stress mgmt for ASA III,IV
4. have patient bring inhaler to dental office
5. avoid anti-histamines (cause mucus thickening)
6. aspirin, nsaids, penicillin, codeine, morphine can precipitate allergies or asthma attacks
7. follow rule of 2s if applys
8. treat in semi-sitting position if ASA III, IV
What are the AAAs with asthma?
Anesthetics:
well controlled (ASA I/II): xylo with epi/marcaine/citaneste forte/articaine max 2 carpules
poorly controlled (ASA III/IV): avoid epi, carbocaine/citaneste plain

analgesics: avoid narcotics in ASA III/IV

antibiotics: avoid macolides with most asthma meds
steps to treating an asthma attack in office:
use patients own meds or metaproterenol puffs or SC/IM epi

upright position

give O2
COPD is a disease state associated with what two conditions?
emphysema and chronic bronchitis
What is the leading cause of COPD?
smoking
What pulmonary condition is associated with alpha 1 antitripsin deficiency?
COPD
what are the PO2 classifications for COPD?
Mild: PO2 close to 75mmHg, PCO2 normal

Mod: PO2 close to 60mmHg, PCO2 normal

Severe: PO2 is less than 50mmHg, PCO2 is increased to around 50mmHg
What are the treatments of COPD?
smoking cessation, bronchodilation, inhaled steroids, oxygen
What are the dental guidelines for treating COPD patients?
upright position, only use O2 during emergency (hypoxia stimulates respiratory center), avoid epi, avoid NO2 + O2 (use low dose diazepam in mild COPD), avoid narcotics, any analgesics causing allergy, follow guidelines for any asthma meds taken
what are the two tests for MTB diagnosis?
PPD test and Quantiferon TB Gold test
what form of TB does someone have with a positive skin test and negative X-ray?
latent TB
what are the 4 types/forms of TB?
Latent, Active, MDR-TB, XDR-TB
what is the drug regimen for latent TB? Active TB?
latent: Izoniazide (INH) for 6-9 months (HIV 9 mo)

active: RIPE for two months, then INH/Rifampin for 7 mo
TB drugs can cause what condition has a side effect?
hepatitis
What TB drug is associated with neuropathy (circum oral tingling and numbness)?

Which is associated with orange discoloration of bodily fluids?
INH

Rifampin
DDIs with anti-TB meds
anything that requires 3A4 enzyme because liver is depressed.

macrolides and tetracyclines, azole antifungals, methadone
Dental guidelines for treating non-symptomatic, symptomatic non-coughing, and symptomatic coughing TB patient
non-sympt, non cough: patient can have routine dentistry (is not infective)

symptomatic, non coughing: patient can be treated after clearance from MD 2-4 weeks after initial TB therapy

symptomatic coughing: obtain clearance from MD after 2 months of initial therapy
what labs should be evaluated prior to dentistry on a TB patient?
liver function test, serum creatinine, CBC with platelets and WBC diff
what instrument should be avoided in the first month of treatment of a patient being treated for TB?
high speed handpiece, causes aerosol
What are the AAAs that can be used with TB?
anesthetics: use no more than 2 carpules

analgesics: no aspirin/nsaids/es tylenol/meperidine/propoxiphene
use reg strength tylenol/vicodin/percocet/apap + codeine

antibiotics: avoid macrolides, ampicilin, tetracycline and metronidazole
use: penicillins, clinda, cephalo
mycobacterium avium intracellulare and mycobacterium kansassi only occur in what patients?
HIV positive
What is the oral dose regimen for valium?
valium:
<age 50: 5-10 mg hs, 5-10 mg PO 1 hr prior
>age 50 healthy, or lean and petite patient: 2-5 mg hr, 2-5 mg PO 1hr before
What is the oral dose regimen for ativan?
Ativan: 1-2mg PO hs, 1-2 mg PO 30 min-1hr prior to Rx
what is the treatment for acute anaphylaxis?
supine position
monitor ABCs
Activate EMS
Start IV line
give epinephrine 0.3-0.5 ml of 1:1000 epi
give diphenhydramine IV 50 mg
give cimetidine IV 300 mg
Give Solu-Cortef IV 100-200 mg
Give O2 (4-6 L/min)
acheiving anesthesia in a patient allergic to ALL anesthetics
1% diphenhydramine solution with 1:100,000 epi

3-4 ml infiltration only

max dose: 50mg benedryl
what are the associated side effects with: chamomile, garlic, ginger, ginko?
chamomile, garlic, ginger, ginko: interfere with blood clotting and may cause post-op bleading
what are the associated side effects with echinacea?
echinacea: inhibits wound healing and increases the risk of post-surgical infection, give antibiotics if on this herbal post-op
what are associated side effects with the herbal, ephedra?
can cause abnormal heart beat, extreme BP elevation and coma when combined with certain antidepressants and anesthetics
What are associated side effects with ginseng?
can cause arrythmias and interact with epi in LA and cause arrythmias, can cause bleeding during and after surgery, should be stopped 7 days prior to surgery
what herbal has DDIs with blood thinners and several BP medications?
st johns wort
what is the general rule with herbal medications and dentistry?
all cause platelet dysfunction and should be stopped 7 days prior to major surgery
how much cortisol is released in a normal healthy patient? what time of day?
20 mg, between 2-8 am
What is the equivalent of corisol with prednisone and hydrocortisone?
20 mg Cortisol = 5 mg Prednisone = 20 mg Hydrocortisone
What is the max amount of steroids for stress, endogenous and exogenous
100-160 mg cortisol = 25-40 mg prednisone PO = 100-160 mg hydrocortisone PO/IV
protocol for patients on daily steroids for a planned surgery.

emergency dental surgery:
for planned surgical procedures:
double dose day before surgery, double again day of surgery, half day after surgery, half again back to normal 2 days post op

emergency:
1 hr prior give 25-40 mg prednisone or 100-160 mg hydrocortisone

step down as in planned procedure over 48 hrs
if patient is on alternate day steroids, should they be treated on the on or off day? morning or afternoon?
on the day steroids are taken, in the morning
prescribing steroids for:
mild (4 or less extractions, 1 quad flap)
mod (5-16 extractions, 2 quad flap)
and severe (17 or more extraction, 3+ quad flap) surgical stress
mild: if patient on steroids, double dose on surgery day, if not on steroids, give 25 mg hydrocortisone PO/IV or 5mg prednisone 1 hr prior

mod: 50-75 mg hydrocortisone PO/IV or 15-20 mg prednisone PO 1 hr prior

severe: 100-160 mg hydrocortisone PO/IV or 25-40 mg prednisone PO 1 hr prior

consult MD always with major
how is diabetes diagnosed?
FBS > 126 mg/dL, PPBS > 140, RBS > 200, OGTT > 200
what is normal HbA1C? what is the Average blood sugar equivalent for 6% HbA1C, 7%, 8% and 9%
Normal (4-5.9%)

6% = 120 mg/dl
7%= 150 mg/dl
8%=180 mg/dl
9%= 210 mg/dl
What is the recommended maintanence level of HbA1C for diabetic patients?
below 7 percent
what are the insulin types?
regular, NPH, Lente, Ultralente
What are sulphonylureas used to treat?
they are oral hypoglycemic agents used in diabetic patients
what type of diabetic will be on oral hypoglycemics?
type II only, type I cannot produce insulin and oral hypoglycemics typically try to stimulate the pancreas to secrete more insulin.

type I diabetics will only be on insulin
true or false?
• Type II diabetes can occur at ANY age (classically below age 14 but can happen as young as 2 yrs)
• Type I diabetes, while previously called juvenile onset, can arise in people in their 60s and 80s
both true
what hypoglycemic agents are known for causing rebound hypoglycemia?
sulfonylureas such as glucotrol
what would be suspected if a patient presented with:
o Perspiration, cold, clammy palms and soles
o Shivering
o Tachycardia
o Increased BP
o Prominent gag reflex (patient pushing drinks away, don’t force them, they could aspirate)
moderate hypoglycemia
o Patient starts looking very glassy-eyed (one too many drinks)
o Unconsciousness, seizure, becomes flaccid
o Unconsciousness associated with bradycardia, lowered BP, lowered temperature

all signs of what?
severe hypoglycemia
how long can the brain go without carbs?
3 minutes
what are the treatment instructions for hypoglycemic shock?
o Monitor ABCs
o Upright position for conscious patient
o Horizontal position for unconscious patient
o Give Oral Glucose to conscious patient
o Give D50W IV or 1 mg Glucagon IM to the unconscious patient
 **Do NOT give as bolus, will cause potassium imbalance, give as drip
 *Can be difficult to find vein due to low BP, if this is the case, give 1 mg Glucagon IM in the deltoid
If a patient brings in blood sugar lab that shows a FBS of 145 at 1 pm, is this a diabetic patient?
not likely since time of blood draw FBS was taken after lunch time
true or false, improvement in blood sugar and HbA1C occurs with periodontal treatment
true
In what condition will Periodontal inflammation patients have evelated C-reactive protein (CRP) level
diabetes
what antibiotics should be used to treat early and late infections in diabetic patients?
early: amox
late: clinda
at what HbA1C value should a patient not be treated and a med consult should be done?
above 8%
what levels should be assessed in a diabetic patient?
FBS, PPBS, HBA1C
When should diabetic patients be treated?
on a full stomach, in the morning
what are the FBS, PPBS, and HbA1C in a well controlled diabetic patient?
FBS < 126, PPBS < 140, HbA1C < 7%
T or T, pain is not good indicator of severity of infection in a diabetic patient
T, this is because of neuropathies that are common,

treat even mild infections aggressively for 5 days
what are the "sick day rules of insulin"?
stress causes epinephrine release which increases blood sugar values, more units of insulin may be added during these sick days, as determined by MD
how might insulin dosing change after a full mouth extraction?
since patient will be eating less, insulin dose may be lessened by up to 50%, consult with MD
what is an important piece of information needed from a patient on an insulin pump?
when their snack times are
what are the guidelines for anesthetizing and treating infections in patients with well controlled and moderate controlled diabetes?
poorly controlled diabetes?
well controlled: can use lido
mod: marcaine, citanest forte
max 2 carpules
full antibiotic dose for infection mgmt

poorly controlled: no epi (max 2 carp)
use lowered dose of antibiotics (even for large patients) BECAUSE patients are extremely susceptible to opportunistic infections***

poorly controlled
What are the FBS, PPBS, and HbA1C for well, moderate, and poorly controlled diabetes?
well controlled (<126, <140, <7%)
mod(126-140, 140-200, 7-8%)
severe(>140, >200, >8%)
A 280lb male with type I BM
FBS = 150 mg/dl
PPBS = 230 mg/dl
HbA1C = 8.9%

has acute abscessed tooth symptomatic for 2 days

what antibiotic/dose used to treat this patient?
Amox 250mg q8h for 5 days

even though patient is large, do NOT use 500mg dose because this patient is severely susceptible to opportunistic infections
PTU/Methimazole/Tapazole are drugs taken by what kind of patient?
hyperthyroid patient, these are anti-thyroid drugsthey
Upon this discontinuation of the anti-thyroid drugs PTU/Methimazole/Tapazole, what is the patients disease status?
they are considered euthyroid
What are the side effects of PTU/Methimazole/Tapazole used to treat hyperthyroidism? what labs should be assessed?
has anti-vit k activity (assess PT/INR)

causes agranulocytosis causing opportunistic infections
(WBC with ANC counts, follow ANC guidelines)

can cause thrombocytopenia (get CBC with platelet count)
What is an important thing to remember with hyperthyroid patients on Beta Blockers?
beta blockers mask hypoglycemic reactions and sweating is the only symptom that occurs
what are the AAA guidelines for hypothyroid patient?
avoid epi in uncontrolled,
use xylo max 2 carpules in controlled

avoid narcotics in uncontrolled

no restrictions once patient is euthyroid or controlled (any narcotic/antibiotic)
what syndrome has increased cortisol levels?
cushings
what are the dental alerts for cushings patients?
monitor BP carefully at every dental visit, patients are more susceptible to infection because of suppressed immune system, increased risk for periodontitis, osteoporosis
What drugs should absolutely be used when treating a dental infection in an addison's patient?
steroids, and benzos or n2o + o2 (decresses cortisol demand)
when should a patient with addison's disease be treated?
1st appointment of the day because of highest basal cortisol level in the morning
true or false, hydrocortisone is 4x more potent than prednisone.
false, prednisone is 4x more potent than hydrocortisone
what takes longer, osteoclastic or osteoblastic activity?
osteoblastic activity takes 2-3 months whereas osteoclastic activity takes 7-10 days
N-telopeptide and C-telopeptide are the biochemical markers of what?
bone resorption
what affect to Bisphosphonates have on bone remodeling?
BPs disrupt the bone remodeling cycle by inhibiting osteoclastic activity, thus increasing BMD (bone mineral) density by decreasing bone resorption
which test is more reliable as a predictor of bone resorption, NTx or CTx?
NTx
What is the halflife of bisphosphonates?
10 years!
What are the four mechanisms of action of bisphosphonates?
• BPs inhibit osteoclastic activity: This leads to reduced activation of osteoblasts & reduced bone formation
• BPs inhibit Vascular Endothelial Growth Factor (VEGF): VEGF is a signal protein causing vascular growth; inhibition decreases vessel growth & angiogenesis
• BPs activate the immune system: Tumor cells are directly killed because of activation of the gamma delta T cells
• BPs have anti-cancer activity: BPs induce tumor cell apoptosis; BPs decrease the adhesion of cancer cells to bone & BPs decrease invasive capacity of tumor cells
what are 3 side effects of bisphosphonate use?
esophagitis, esophageal cancer, bisphosphonate related osteonecrosis of the jaw
Which has a higher susceptibility to ARONJ?

Cancer patients or osteoporosis pts?
mandible or maxilla?
+ or - H/O surgery?
monthly IV or weekly oral/yearly IV?
cancer patients (12x higher dose)
mandible 2:1 (less vascular)
positive history of surgery
monthly IV
What conditions are treated with BPs?
osteoporosis, Paget's bone disease, metastatic bone disease
what is a more important predictor of ARONJ susceptibility, BP route (IV or PO) or total dose of BP/year?
total dose
When does the risk of ARONJ increase for cancer patients? for osteoporosis patients?
cancer patients - 16-24 months
osteoporosis - 4+ years
what are HIGH risk radiographic findings for ARONJ?
thickened lamina dura, osteosclerosis, widened PDL
What is EXTREMELY IMPORTANT to analyze in patients taking bisphosphonates?
dental radiographs (look for widened PDL, osteosclerosis, and thickened lamina dura) all signs of ARONJ
what is the dentists role in providing care to those prior to starting bisphosphonates for cancer or osteoporosis?
take full set of radiographs, eliminate all foci of infection, root canal more preferable than extraction

make sure to provide post op antibiotics after all surgeries because the main cause of ARONJ is soft tissue injury with subsequent infection
with what hepatitis is there lifelong immunity with recovery?
hepatitis A
What are the chronic types of hepatitis?
B,C,D
can a patient ONLY have hepatitis D?
NO, the patient must also have hep B
At what point after hep B infection will surface antigen show up? go back down to baseline levels?
7-20 weeks
What is the significance of a patient having HBsAg, DNA-P, and HBeAg?
This is when the viral infection is extremely active, defer treatment
What is the window period in a hep B Ag-Ab cycle?

Is the patient infective in the window period?
It is between weeks 20 and 24 when patient is negative for surface antigen, e antigen, DNA-P AND negative for surface antibody

but they do have core antibody (IgM).

YES because they do not have
What kind of antibody is Hep B core antibody? What does it indicate?
Initially IgM (turns to IgG after 6 months, wk 24)

Core antibody indicates past infection with HepB, not necessarily recovery from an infection (surface antibody must be present)
Is core Antibody present when you gain immunity with a Hep B vaccine?
No, you will only have AntiHBc with a natural infection
What is a patient considered when they are shedding Hep B surface antigen beyond 24 weeks?

What is a patient considered when they are shedding Hep B surface antigen and e antigen beyond 24 weeks?
a simple carrier; a super-infective carrier
What kind of antibody will hep B core antibody be if the patient was infected over 6 months ago from a natural infection?
IgG
The highest number of cirrhosis from viral infections occurs from what?
hep C
The highest number of liver transplants are from what disease?
Hep C
what are the two tests for Hep C? What do they indicate/not indicate?
the anti-HCV test, and HCV RIBA Test.

They indicate past exposure, NOT the presence of active viral infection
What does the HCV-RNA test indicate?
whether or not the patient is chronically infected (positive) or has cleared the infection (negative)
What test is used to determine response to anti HCV therapy? What indicates success of Rx?
Viral load HCV test. at least 99% decrease in viral load
how many genotypes of HCV are there? which is the most common?
6 genotypes. Genotype 1 is most common (and is less likely to respond to treatment)
Should a patient be treated for dental conditions before or after undergoing Hepatitis treatment?
Before, just like in transplant patients. Get rid of all foci of infections before treatment is started. The medication is very debilitating and immunosuppressive.
What are the associated LFTs with Hep C?
AST and ALT will be decreased usually. They will be less than 500.
What should you do if you get a needle stick?
wash hands with soap and water. go with patient to employee health for testing and blood draws.
What are the differences between LFTs from acute and chronic hepatitis?
Acute: ALT will be >2000, AST > 2000

chronic: mildly increased or normal

BOTH will have ALT>AST
Will the albumin levels be declined in hepatitis?
never, they will always be normal
How do you differentiate between hepatitis and cirrhosis based on LFTs?
Hepatitis: ALT>AST
Cirrhosis: AST>ALT
What is the leading cause of cirrhosis? most common type of hepatitis?
Alcohol
When will the albumin and globulin levels be decreased in LFTs?
cirrhosis only

the ratio of A:G will be reversed (is usually 2:1)
How do you tell the difference between alcoholic cirrhosis and cirrhosis from viral hepatitis based on LFTs?
in alcoholic hepatitis/cirrhosis AST is always greater than ALT at a ratio of 2:1

in other cirrhosis types, the ratio is not 2:1
When is GGT elevated in liver conditions?
alcoholism and bile stasis(extremely increased)
When will the PT/INR be prolonged in liver disease?
In cirrhosis or bile stasis
what are important labs to get for patients with hepatitis or cirrhosis?
CBC with platelets, hepatic serology, viral load, LFTs and PT/INR
Which hepatitis antibody is a marker of infection, NOT recovery?
hep C antibody (Positive RIBA test)
what does markedly elevated liver enzymes with normal albumin indicate?

what does mildly elevated liver enzymes with normal albumin indicate?
active hepatitis; chronic hepatitis
prior to probing cirrhotic patient, what must be obtained?
PT/INR

must be less than 2 or else you need replacement therapy
Is a cirrhotic patient premedicated?
only when they present with ascites
T or F, cirrhotic patients can have thrombocytopenia.
True
Can a cirrhotic patient be premedicated with amoxicillin?
**FIRST CHECK RENAL FUNCTION (S Cr, BUN, GFR).

Cirrhotic patients may have renal dysfunction, it not, amox can be used.
If a patient has cirrhosis and some amount of kidney disease, what is used as a premed antibiotic?
clindamycin
What are the AAAs with liver disease?
Anesthetics: use any, max 2 carpules. (complete dental treatment over multiple visits)(avoid epi with associated kidney disease)

Analgesics: tylenol. (Avoid chronic use) Hydromorphone or fentanyl (NORMAL DOSE OK), Codeine, vicodin, percocet (prolonged interval)
AVOID ASPIRIN, NSAIDS, MORPHINE, MEPERIDINE, PROPOXYPHENE.

Tramadol - use dose modified in liver disease, avoid in cirrhosis

Antibiotics:
Pen VK, amox, keflex/duricef, clarithro, azithro (except with cirrhosis), clinda okay. doxy okay, flagyl (decrease dose)

avoid ampicillin, tetracycline
Can patient drive after Ultram is given?
no, even though it is non-narcotic still causes drowsiness
what are the tests done for HIV?
ELISA test, then western blot test
When a patient tests positive for HIV, what tests are done routinely?
CD4 count, and viral load
what are protease inhibitors used to treat? what are the important side-effects of protease inhibitors?
HIV,

side effects: heart disease, hyperlipidemia, lactic acidosis, insulin resistance and pancreatitis
what lab tests should be assessed with patients on HIV meds?
CBC, LFTs, Renal Function, FBS, Lipid profile
Which is a better indicator of ability to heal in an HIV patient, CD4 or ANC?
ANC
how will you know if patient is HIV positive if CD4 count is above 200?
The patient will always be on PCP prophylaxis
how do you convert between lymphocyte percent and CD4 count in an HIV patient.
>30% = CD4 count >500
15-30 = CD4 count 200-500
<15% = CD4 count <200 (full blown aids)
During vasovagal syncope, what is the SBP when you cannot feel the radial pulse? the brachial pulse? what about the carotid pulse?
radial pulse - SBP below 80mmHg
brachial pulse - SBP below 70mmHg
carotid pulse - SBP below 60mmHg
what are the most common predisposing factors of hyperventilation syndrome?
anxiety and fear
Should hyperventilation patients be given oxygen?
no. they should cover their mouth to recapture CO2 that is being washed out.
does collapse occur in hyperventilation syndrome?
no, patient just feels like it will
what are the 4 components of the ictal phase?
the aura, tonic, clonic, and flaccid phase
during what phase of grand mal seizures do you, as a provider, step in? what do you do?
Flaccid phase, before then, just try to prevent injury.

During the flaccid phase, confirm the patient has regained consciousness (shake, or pinch), clear airway with suction, chin lift, tilt head to the side.
What is dilantin used to treat?
used in the management of grand mal epilepsy.
What are the DDIs with dilantin?
avoid salicylates, diazepam, avoid doxycycline (it is a potent CYP3A4 inducer)
What oral finding is seen with Dilantin?
gingival hyperplasia
What is the main difference between grand and petit mal seizures?
consciousness is not lost in petit mal seizures
What should be checked in history when a patient is on seizure medications?
a history of alcohol (which can decrease the potency of seizure meds)
What is the general guideline, (what do you avoid) with antiseizure medications?
avoid centrally acting pain meds, sedatives, hypnotics, narcotings, and antihistamines.

use regular strength tylenol

avoid doxy, clarithromycin, steroids, metronidazole
what type of anemia does dilantin lead to?
folic acid deficiency (macrocytic anemia).

obtain CBC and follow AAAs for anemia if CBC indicates the need
What are the anesthetic guidelines with patients who experience seizures?
in patients with frequent seizures: no epi or epi cords (use hemodent)

in patients with less than 1-2 seizures a year: epi is okay
what do PPIs treat?

What are their side effects?
GERD.

they interfere with absorption of calcium, inhibit osteoclasts, these individuals have an increased risk of fractures
What antibiotic shoud be avoided when the patient is taking PPIs?
ampicillin (needs a low pH)
How long should H2 blockers be used in GERD treatment?
should not be used for more than a few weeks
What drugs should be avoided when patient has GERD?
avoid aspirin and NSAIDS, corticosteroids.

avoid tetracyclines and ampicillin with antacids
what labs must be evaluated in patients with celiac and crohn's disease?
evaluate CBC(iron impaired), PT/INR (they have impaired vit K absorption), dental radiographs (calcium absorption impaired)

evaluate diabetes tests
what is the drug of choice for treating mild/mod c. defficile? severe? what is the regimen?
mild/mod: metronidazole, 10-14 days, 500mg TID

severe: vancomycin 125 mg QID 10-14 days
How is mild/mod and severe C. Defficile infection identified?
mild/mod: WBC < 15,000 cells and S. Cr < 1.5 times normal level

severe: WBC > 15,000cells OR S Cr. > 1.5 times normal level
what analgesic should be avoided when a patient is on anti-diarrheal meds such as immodium?
codeine, as it will have an additive effect (severe constipation)
Celiac patient on sulphasalizine, must treat dental infection, what drug should be used?
sulphasalizine is a sulpha drug (bacteriostatic)

should give with static drug such (macrolides/tetracyclines)
how do you treat HIV gingivitis?
give optimal OHI, scaling a root planing, provide non alcoholic chlorohexidine rinse
what drug is the drug of choice for treating HIV periodontitis?
metronidazole (UNLESS PATIENT IS ON PIs or is an alcoholic)

alternatively, use clinda, keflex, augmentin, cipro

use lowest strenth to prevent candida
What is a preperation that can be used for recurrent aphthous ulcers?
mix 1 teaspoon of benadryl and 1 teaspoon of kaopectate, rinse, gargle and expectorate!
when is pilocarpine contraindicated?
when patient has moderate to severe asthma, COPD, cardiac arrythmias, H/O renal/ gall stones, narrow angle glycoma
what is the dosing of pilocarpine?
5mg/tab, 1-2 tabs tid/qid 30 minutes prior to meals, minimum Rx for 90 days.

medication may not become effective until 1-3 months after taking
What condition(s) is/are treated with Imuran? what category of drug is this?
Rheumatoid arthritis and transplant patients.

DMARD (disease modifying anti-rheumatic drug)
What drugs should be avoided with COX-2 inhibitors?
fluconazole, tetracycline, doxycyclin, Clarithromycin.
What labs should be obtained in patients with rheumatic diseases?

what wbc diff value is important to assess?
CBC, S Cr, LFTs, WBC diff

monocyte count- an increase suggests flare up (defer routine dental treatment)
what drugs, commonly taken by rheumatic disease patients, should be stopped 2 weeks prior to dentistry when white counts are low?
TNF-blockers
what labs must be assessed with a transplant patient is taking imuran?
CBC with WBC diff (causes leukopenia), and platelet count (can cause thrombocytopenia)
what is a common side effect of imuran that can be treated by the dentist?
mouth sores, can be treated with benadryl and kaopectate
what drugs should be avoided in patients on cyclosporine?
nephrotoxic drugs, NSAIDS, macrolides, azoles (3A4 inhibitors), H2 blockers,
What is a common side effect of cyclosporine?
gingival hyperplasia
What transplant drug can raise S Cr and BUN causing HTN if not well regulated?
cyclosporin
is the rule of 2s followed for all procedures in a patient taking prednisone?
no, just major procedures
how long should routine dentistry be defered post transplant?
6 months
what is an important dental consideration for a patient preparing to have an organ transplant?
treat all lesions likely to cause pain or infection or bacteremia before transplantation
What labs should be obtained in the pre-transplant patient? post transplant?
pre-transplant: CBC, ANC count, PT/INR (liver), platelet count (liver)

post transplant: appropriate labs to evaluate status of transplanted organ
What questions should be asked to a patient recieving radiotherapy for cancer?
Is it above or below the clavicle?
If above, how much radiation and when?
patients receiving > 65 Gray or 6500 RADS are at increased risk for what condition?
osteoradionecrosis
What are the short term side-effects of radiation therapy? long term?
short term: mucositis (3rd week) and altered salivary gland function

long term: 3 H's (hypoxia, hypovascularity, and hypocellularity)
What are the three H's of radiation therapy, to they worsen or become better over time?
hypoxia, hypovascularity, and hypocellularity. they become worse over time.
Patient had cancer and received chemotherapy treatment 5 years ago. What must be clarified before deciding whether or not to premedicate?
Is the chematherapy access catheter still in place? if so, premedicate.
When should dental treatment take place after radio/chemotherapy has commenced?
2 weeks after the treatment is over.
How is "phantom tooth pain" associated with chemotherapy treated?
with benzos
what site of the jaw is most susceptible to ORN?
the anterior part of the mandible
which causes more susceptibility to osteoradionecrosis, implant radiation or external source radiation?
implant radiation.
what are the guidelines for post-radiation extractions following a total dose of <6500 RADS? or >6500 RADS?
<6500 RADS: Best done >1 yr after radiation therapy, followed by pen VK/clinda for 5 days to promote healing

>6500 RADS: hyperbaric O2 is strongly suggested prior to extractions
What labs should be obtained before treating a patient who has undergone chemo and radiation therapy?
CBC with platelets, WBC diff (CALCULATE ANC!), PT/INR
what analgesics can be used in patients who have undergone chemo-radiotherapy?
tylenol, codeine, morphine, demerol, fentanyl
how do you treat mucositis associated with radiation therapy?
tell the patient to mix 2 tsp salt and 2 tsp baking soda in 8 oz cold water and rinse and expectorate
How are the trimesters of pregnancy divided by weeks?
first trimester: 1-12 weeks
second: 13-28 weeks
third: 29-40 weeks
What weeks does organogenesis occur?
3-10 OR when patient is experiencing morning sickness
how is pregnancy hypertension diagnosed?
either increase in SBP by 30 and/or DBP increase by 15 (since before pregnancy prior to 20 weeks preg) OR >140/90 if previous readings are unknown
What is expected to happen to pregnanct patient vitals int he 2nd trimester?
BP should drop. (stop tx and defer if this does not happen)
when is the safest and most comfortable time for dental treatment during pregnancy?
last 2-3 weeks of 1st trimester, all of second trimester, and first half of 3rd trimester
AAAs and stress mgmt that can be used during pregnancy
Anesthetics: 2% lido with epi (max 2), citaneste forte, citaneste plain (used in preg hypertension)

Analgesics: Ibuprophen, naproxin can be used during 1st 2 trimesters if absolutely needed (with OB consent). Can use percocet, tylenol.

Antibiotics: pen, ceph, azithro, clinda. (use clinda with pen to treat late infections)

Stress mgmt: avoid NO2 + O2
what are the AAAs with lactation?
anesthetics: anything (but have mother pump and discard to avoid mastitis)

analgesics: anything, but keep 2 hr interval. take pain meds after breast feeding. (use lower doses of opiods)

antibiotics: penicillins, cephalosporins, macrolides, clinda (keep 2 hr interval, ex. give azithro once a day)