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Tuesday, August 31, 2010

Oral Medicine

Intro: Menulis ringkasan nota di blog adalah satu cara yg efektif (bagi saya) untuk menghilangkan mengantuk ketika study. Maafkan saya wahai pembaca yang budiman jika tidak memberi manfaat buat anda. Blog saya ni sejak dari dulu lagi memang multi-purpose... ;)

MEDICALLY COMPROMISED PATIENTS ; ORAL HEALTH CONSIDERATIONS
A brief
  • Hypertension:
1-asymptomatic BP= below 159/99, no target organ disease --->no dental modifications needed, can safely be treated in a dental outpatient setting.

2-asymptomatic BP= 160-179/100-109, no history of target organ disease
--->assessment on individual basis with regard to type of dental procedure.

3-BP > 180/110, no history of target organ disease ---> no elective dental care.

4-target organ disease or poorly controlled DM---> elective dental care only when BP is controlled preferably.

  • Coronary artery disease
1-if bleeding time >15-20 minutes --->1 desamino-8-D-arginine vasopressin (DDAVP) is administered parenterally 0.3ug per kg of body weight within 1 hour of surgery.

2-3 different protocols (elevated INR):
a) warfarin is not discontinued
b) warfarin therapy is discontinued; 2-3 days before and 2-3 days after surgery
c) warfarin therapy is discontinued and replaced with heparin

  • Valvular heart disease (mitral/aortic/prosthetic)
1- (AHA)
2- the risk of thromboembolism increases for prosthetic heart valve patients is anticoagulation therapy is discontinued. It is prudent to continue anticoagulation therapy in patients who require intensive high INR levels.

  • Heart failure
1- no special modifications unless the underlying causes for the heart failure require modifications.

2 - lying down flat (supine) in a dental chair may cause severe dyspnea in such patients.

  • Gastroesophageal reflux disease (GERD)
1-patients may complain of dysgeusia, dental sensitivity, erosion or pulpitis.
2-may need to treat in a semisupine position and premedicated with H2 receptor antagonists or antacids.
3-cimetidine inhibits the absorption of the systemic antifungal drug ketoconazole --->blood concentration (remember!)

  • Hiatal hernia
1-may have xerostomia due to medications used--->tx: artificial saliva, alcohol-free mouthwash, increase fluid intake
2-may have class V caries or root caries--->because of xerostomia
3- may have oral manifestations such as GERD--->if reflux into oral cavity

  • Peptic ulcer disease
1-avoid lengthy dental procedures--->minimize stress!
2-avoid administering drugs that exacerbate ulceration and cause GI distress (aspirin, NSAIDS)
3-acetaminophen products are preferable and are recommended.
4-may need sedation--->if stressful
5-antibiotics should be taken 2 hours before/2 hours after ingestion of antacids--->because antacids decrease absorption of antibiotics!
6-avoid exogenous steroid administration---> increase acid production!
7- prescribe penicillin V instead of penicillin G --->destruction of penicillin G by gastric acid!

  • Ulcerative colitis
1-the risks associated with anemia contraindicate surgical treatment until the disease is under control.
2-may have apthous stomatitis--->nutritional deficiencies of iron, folic acid and vit. B12 or blood loss!
3- anti inflammatory medications such as 5-aminosalicylates can cause apthous ulcers.
4-pyoderma gangrenosum may occur.

  • Crohn's disease
1-may reveal mucosal ulceration.
2-before surgical procedures are formed;
-complete blood count
-hematocrit
-hemoglobin test
-platelet count
-coagulation studies
-liver function test
-blood glucose test

  • Alcoholic hepatitis
1-may have--->jaundice, petechiea & ecchymoses, gingival crevicular hemorrhage, thrombocytopenia, pallor, angular chelitis, glossitis, sweet ketone breath.
2-should warrant a referral to the patient's primary care physician for evaluation.
3-elective dental treatment should not be carried out in a patient who has ingested a large amount of alcohol.

  • Liver cirrhosis
1-may have--->angular chelitis, glossitis, mucosal pallor, yellow pigmentation on oral mucosa, salivary gland dysfunction.
2-lab evaluation before any surgical /periodontal procedures should be obtained--->patients may have significant hemostatic defects.
3-avoid the use of sedatives and tranqulizers in patients with a history of taking encephalopathy narcotics.

  • Polycythemia
1-may have--->purplish red discolouration of the oral mucosa, reddish gingiva, petechiae and ecchymoses, varicosities in the ventral tongue.
2-possibility of bleeding or thrombosis.
3-should have a complete blood count prior to treatment.
4-hemoglobin be reduced below 16g/dL and hematocrit to below 47%--->to avoid complications!
5-preoperative myelosuppressive treatment before dental treatment when blood counts are not controlled.

  • Anemia
-general symptoms; pallor of the skin, palpebral conjunctiva and nail beds, dyspnea and easy fatigability.

  • Granulocytosis
1-may have oral ulcers (foul smelling), advanced periodontal disease, pericoronitis, and pulpal infections.
2-the infection must be cultured to determine the predominant organism.
3-patient should be placed on the appropriate combination of parenteral broad-spectrum antibiotics.
4-topical application of antibacterial mouth rinses helpful for ulcers.
5-a combination of topical neomycin, bacitracin and nystatin--->to reduce the risk of severe infection.

  • Leukemia
1-cervical lymphadenopathy, oral bleeding, gingival infiltrates, oral infections and oral ulcers.
2-should always weigh the risk of platelet transfusions against their benefit before recommending their use for treatment of oral bleeding.
3-topical treatment to stop gingival bleeding; removal of obvious local irritants and direct pressure.

  • Lymphoma
-sign; asymptomatic enlargement of the cervical lymph node chains, without signs of infection, more than 1 lymph node chain is involved or a lymph node of 1 cm or greater in diameter persists for more than 1 month.

  • Multiple myeloma
1-jaw lesions--->first evidence
2-pain, swelling, numbness of the jaws, epulis formation, or unexplained mobility of the teeth.
3-skull lesions--->more common than jaw lesions
4-hemorrhage and infection (bleeding from thrombocytopenia, abnormal platelet function, abnormal coagulation, or hyperviscosity)
5-if surgery is necessary--->obtain recent results of platelet count, bleeding time, PT and APTT.


Reference:
Prof. Nazih Syaaban's lecture notes

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