ࡱ> 5@ bjbjw:w: +PPdPPPPPPPdlWlWlWlW|Wd1~2YZZZZZZZt}v}v}v}v}v}v}$cR}QP]ZZ]]}PPZZ}qqq]&PZPZt}q]t}q2qrtPPtZY ylWn.tv~01~t,?n?tddPPPP?PtZJ[q[l<\gZZZ}}ddd?Aq ddADiseaseEtiologyGeneral InfoDental ManagementHypertensionIdiopathic/Essential-90% Secondary-10% (kidney dx, drug induced, thyroid disorder) Normal - <120/80; Prehypertension  120-139 / 80-89 Stage I  140-159 / 90-99; Stage II - e"160 / e"100 Adrenergic Receptors: 1 & 2  peripheral arterioles = vasoconstriction 1  heart = !cardiac output and heart rate 2  skeletal muscle arterioles = vasodilation 1 2 1 2 Epi +++ +++ +++ +++ Norepi ++ ++ ++ + Levonor + ++ ++ + -Defer elective tx if e"180/110 -Caution with epi with non-selective -blockers (Propranolol/Inderal and Nadolol/Corgard) -Norepi & Levonordephrin potentially ! BP  less effect with epi (limit to 2 carp. 1:100,000) -Control of orthostatic hypotension -Monitor BP before and during appt(stage II)Ischemic Heart DiseaseCoronary atherosclerosisSigns & Symptoms: Very few unless MI -chest pain -shortness of breath -sweating -easy fatigueRecent MI (w/in 1 month) or Unstable Angina: -Avoid elective tx -If tx is necessary; MD consult -Prophylactic ntro -Consider N2O2; sedation; pulse ox; monitor BP -Caution with epi Past MI or Stable Angina: -Short morning appt. -Monitor vitals -Nitro ready -Stress reduction (good local, sedation) -Limit epiCongestive Heart FailureRight or left-sided heart failure due to: Coronary heart disease, HTN, cardiomyopathy, valvular heart disease, myocarditis, IE, Pulmonary embolism, endocrine diseaseRight-sided HF effects: increased pressure and fluid retention, venous congestion, and peripheral edema Left-sided HF effects: Increased pressure and fluid retention, pulmonary hypertension, and edema Drug management may include: diuretics, ACE inhibitors, beta-blockers, digitalis, nitrates-For pts taking Digitalis avoid epi (max 0.036 epi and consult with MD) -Short, stress free appts. -Semisupine or upright chair position -Consider orthostatic hypotension -Avoind NSAIDs Watch for digitalis toxicity (tachycardia, hypersalivation, visual disturbances) -Consider N2O2 sedationInfective EndocarditisFungal or Bactial (90% due to Strep or Staph)40% mortality rate Signs and Symptorms: Fever, heart murmurs, + blood culture, petechiae (80% within 2 wks) Antibiotic regimen: Amox 2g; Cephalexin 2g; Clindo 600mg Children Amox/Ceph 50mg/kg; Clindo 20mg/kg -Amox good for 6h additional 2g if longer -If on antibiotics, then switch to different class or wait 10 daysPremed only for high risk: -prosthetic heart valve -previous IE -congenital heart disease (unrepaired, sx w/in 6mo, residual defects) -heart transplant with valvulopathy <20% of endo procedures cause bacteremiaStrokeIschemia or hemorrhage to the brain cerebrovascular diseaseSigns: paralysis, speech impaired, anxiety, dizziness TIA transient ischemic attack mini stroke due to temporary disturbance of blood supply-Delay care for 6mo. -No elective care for TIAs -Short AM appts. -Stress reduction N2O2 -Monitor vitals -Limit epiAsthmaEtiology not well understood Types: -Allergic (extrinsic) 35% seasonal allergens -Nonallergic (intrinsic) -Drug induced -Exercise induced -InfectiousTypical symptoms: dyspnea (breathlessness); wheezing, cough, chest tighness and flushing Management of attack in office: -Administer fast acting bronchodilator (epinephrine Primatene Mist) repeat q 5 min until EMS arive -If needed, subcutaneous 0.3-0.5 mL of epi 1:1000 -Activate EMS Determine character of Asthma: -type (allergic or nonallergic; precipitating factors; age of onset; level of control (recent emergency care); meds and management -consult with MD if severe and persisitant -Avoid precipitating factors -Reduce risk pt brings inhaler to appt and prophylax if moderate to severe asthma -Drugs to avoid: ASA; NSAIDs; narcs and barbiturates; E-mycin if pt taking theophylline -Recognized signs & symptoms difficultly breathing, tachypnea -Pt may be sensitive to sulfite preservative in LA choose LA w/out epiCOPDCigarette smoking chronic airflow limitation that is not fully reversibleTwo most common disease of COPD: Chronic Bronchitis excessive tracheobronchial mucous production (blue bloaters cyanotic with chronic cough) Emphysema distention of the air spaces distal to the terminal bronchioles due to destruction of alveolar walls/septa (pink puffers barrel chested with exertional dyspnea)-Upright chair position -Normal use of LA -No N2O2 if severe case -Pulse ox to monitor - Supplemental O2 if below 95%Sickle Cell AnemiaInherited distortion of the RBC into a sickle shape results from deoxygenation, decreased blood pH or when the pt becomes dehydratedKaya 2004 IEJ SCA is a genetic and systemic disease which may cause pulp necrosis without necessarily having an identifiable etiology. SCA causes radiographically observable differences in jaw structure, especially in the mandible. The clinical problem is directly associated with the defective RBC. The patients are prone to infection because the macrophages are involved in the phagocytosis of the RBC and not available for destroying bacteria. The distorted cells may also occlude the Microvasculature and impede blood flow to an area. This mechanism is suspected by Ingle & Taintor 1985 to be the cause of pulpal necrosis and repeated episodes of pain as described by Andrews 1983 in sickle cell patients. Radiographic observation- stepladder appearance of the widening trabeculation due to increased marrow space (increase hematopoiesis). This increased marrow space is accompanied by thinning cortical plate and irregularities in density. -Manage infections aggressively -Use prophylactic antibiotics for major surgical procedures -Caution with vasoconstrictors -Avoid ASA codeine and acetaminophen in moderate dosage -Use N2O2 with >50% O2 -Short stress free appts.HyperparathyroidismPrimary- caused by adenoma (80%), carcinoma of parathyroid, or PTH release from ectopic malignant tumor. Tx= surgical removal of parathyroid. Secondary- caused by renal disease, vit d deficiency, Ca malabsorption states. Tx= renal dialysis or transplant. Classic signs = stones, bones, groans Ectopic calcifications- kidney stones Bone lesions- lytic lesions (brown tumors, a giant cell granuloma) ground glass appearance with decreased trabeculation Vague abdominal pain, fatigue, weakness Emotional liability, psychoses Lytic lesions may resemble PA pathologyDiabetesType I immune mediated beta-cell destruction or idiopathic Type II insulin resistance with relative insulin deficiency Gestational abnormal glucose tolerance during pregnancyCardinal symptoms: Polydispia, polyuria, polyphagia, weight loss and loss of strength HbA1c reflects glucose level in the blood over the 6-12wk period preceeding the test. Normal pts are between 6-8%. Well controlled diabetics will stay below 7%. Normal premeal plasma glucose levels are 90-130 mg/dL Type I tx includes insulin therapy: Rapid acting lispro, aspart Short acting regular Intermediate acting NPH, Lente Long acting Ultralente, glargine Type II tx includes oral hypoglycemics: Glipizide, Glyburide, Glimepiride sulfonylureas Metfromin, Glucovance biguanides Acubose gamma-glucosidase inhibitors Management includes: -Consider HbA1c levels -Schedule am appts pt should eat normal meal before appt. -Have sugar available in case of insulin rxn -Tx of infections aggresivelyBender IB, Bender AB. Diabetes mellitus and the dental pulp. J Endod 2003. Diabetics are particularly prone to bacterial or opportunistic infections. This vulnerability is caused by a generalized circulatory disorder whereby the blood vessels are damaged by the accumulation of atheromatous deposits in the tissues of the blood vessels lumen. In addition, blood vessels, particularly capillaries, develop a thickened basement membrane, which impairs a leukotactic response, and there is a decrease in the polymorphonuclear leucocyte microbicidal ability and failure to deliver the humoral and cellular components of the immune system. Because the dental pulp has limited or no collateral circulation, it is more prone to be at risk for infection. Fouad AF, Burleson J. The effect of diabetes mellitus on endodontic treatment outcome: data from an electronic patient record. J Am Dent Assoc 2003. A multivariate analysis showed that in cases with preoperative periradicular lesions, a history of diabetes was associated with a significantly reduced successful outcome. CONCLUSIONS: Patients with diabetes have increased periodontal disease in teeth involved endodontically and have a reduced likelihood of success of endodontic treatment in cases with preoperative periradicular lesions. CLINICAL IMPLICATIONS: Patients with diabetes who are treated endodontically should be assessed carefully and be treated with effective antimicrobial root canal regimens, particularly in cases with preoperative lesions. Pseudomembranous ColitisOvergrowth of Clostridium difficileOvergrowth results from the loss of competitive anaerobic gut bacteria, most commonly through the use of broad-spectrum antibiotics, but it can also result from heavy metal intoxication, sepsis, and organ failure Signs and symptoms: loose and watery stools or bloody diarrhea, accompanied by abdominal cramps and fever-Discontinue antimicrobial agent (in mild cases this may resolve) -Oral metronidazole (250mg qid for 10 days) or VancomycinPeptic Ulcer DiseaseHeliobacter pylori & overuse of NSAIDsErosion of enamel may be present with GERD Acid blocking drugs, such as cimetidine, decrease the metabolism of certain dentally prescribed drugs(i.e. diazepam, lidocaine)-Avoid ASA & NSAIDs -Avoid corticosteroids -Examine oral cavity for signs of fungal infection -Stress free environmentInflammatory Bowel DiseaseImmune dysfunction in response to environ. factors in genetically susceptible personsUlcerative Colitis inflammatory rxn of the large intestine with remissions and exacerbations; aphthous-like lesions affect up to 20% of pts. with UC Crohns Disease chronic, relapsing idiopathic disease that is characterized by segmental distribution of intestinal ulcers interrupted by normal appearing mucosa (any portion of the bowel may be involved); Atypical mucosal ulcerations and diffuse swelling of the lips and cheeks may occur-Schedule appts. during remissions -Additional steroids may be needed for surgical proceduresAdrenal Insufficiency-Addisons disease = primary adrenocortical insufficiency -Secondary insufficiency results from hypothalamic or pituitary disease or administration of corticosteroidsConsiderations: -Inability to tolerate stress -Delayed healing -Susceptibility to infection -Hypertension -bronzing of the skin; pigmentation of the lips/oral mucosa Consider steroid supplementation is corticosteroids were taken within the past 2 wks consult with MD-No corticosteroid supplementation for pts taking corticosteroids for routine dental procedures -For minor oral surgical procedures administer 25mg hydrocortisone prior to procedure (50-100mg hydrocortisone for major oral surg approx. 4mg dexamethasone) hospital setting -Monitor BP throughout procedure -Provide good pain controlHyperthyroidismGraves disease autioimmune diseaseOther causes for excess of T4 and T3 in the bloodstread (throtoxicosis) include: ectopic thyroid tissue, mutinodular goiter, thyroid adenoma, subacute thyroiditis or pituitary disease Signs and symptoms include: nervousness, fatigure, rapid heartbeat and palpitations, heat intolerance, weight loss & exophthalmos-Once under good medical management, no tx modifications are indicated -If thryrotoxicosis is not well controlled, then consult with MD; oral infections managed aggresivelyHypothyroidismHashimotos disease is the most common cause of goitrous hypothyroidism - autoimmuneTx with synthetic T3 or T4 (Synthroid) Pts with untx hypothyroidism are sensitive to narcotics, barbiturates and tranquilizers Stressful situations such as cold, operations, infections or trauma my precipitate a hypothyroid (myxedema) coma in untx pts.-Once under good medical management, no tx modifications are indicated -If hypothyroid state is not well controlled, then consult with MDHIV / AIDSHuman immunodeficiency virus family of lentiviruses -HIV can infect most human cell; however, the cells most commonly infected are these with CD4 receptors, including T-helper (CD4 cells) and macrophages -Tx with HAART (highly active antiretroviral therapy) -AIDs is considered with CD4 lymphocyte count <200 -Common oral findings when CD4 count <500: oral candidiasis, hairy leukoplakia, kaposis sarcoma, necrotizing ulcerative perioNo dental modifications indicated for HIV infection with CD4 count >200 Pts in advanced stages of disease should receive emergency and preventive care only -Consider antibiotic prophylaxis due to immunosuppresionOrgan transplantationConcerns of infection from drug induced immunosuppresion Pre-transplant eval & aggressive tx MD consult determine status of pt & discuss need for prophylactic antibiotics Following transplantation: -Immediate posttransplant period (6mo) limit care to emergency needs -Stable graft period tx as normal with frequent recalls -Chronic rejection period emergency dental careCancerOral manifestations of radiation & chemotherapy: -Mucositis -Candidiasis -Xerstomia -Trismus -Cervical caris -Osteonecrosis -Bleeding tendency -Infection -Poor healing-Perform only emergency tx during chemo -Consult MD re antibiotic prophylaxis -If radiation tx >6000cGy, every effort to avoid osteonecrosis (endo tx only & no surgergy)Pregnancy/Breast FeedingOral manifestations include: pregnancy gingivitis, pyogenic granuloma, tooth mobility FDA pregnancy class B drugs: LA Lidocaine with epi (Artic., Bupiv, & Mepi. all class C) Analgesics Acetominophen Antibiotics Pen, metronidazole & clindamycin-Consult MD if concerns about pt status -Second trimester and most of third are best for elective tx -Avoid drugs harmful to fetus -In late third trimester, do not place pt in supine position for prolonged periods Lactation concern: -Administer drugs just after breastfeeding -Most drugs have little pharm significance to lactationBleeding Disorders-Anticoagulation therapy -Congenital disorders Oral manifestations include: excessive bleeding, hematomas, petechiae, ecchymoses Thrombocytopenia: decreased platelet count (concerns below 50,000/mm3 of blood idiopathic or due to leukemia Hemophilia A: factor VIII deficiency Hemophilia B or Christmas disease: factor IX deficiency Von Willebrands disease: defect of vWF; secondary factor VIII deficiency inherited defect of platelet adhesion-MD Consult -For anticoagulation therapy (coumadin), INR 3.5 or less for most surgical procedures (INR taken day of surgery) -Avoid ASA compounds & NSAIDs; use Tylenol with or without codeine for post-op pain controlVitamin D resistant RicketsX-linked dominant trait-decreased reabsorpion of phosphate by the renal tubule (causing  HYPERLINK "http://www.wheelessonline.com/ortho/hypophosphatemia_diff_dx" hypophosphatemia) -decreased absorption of calcium and phosphorous from the GI tractBender IB, Naidorf IJ. Dental observations in vitamin D-resistant rickets with special reference to periapical lesions. J Endod 1985. Pulp horn extension into the DEJ is pathognomonic for Vitamin D resistant rickets. Clinically- frontal bossing, bowing of legs, short enlarged wrists and ankles Dental- hypoplastic/hypo calcified enamel, draining sinus tract, gingival swelling, apical abscesses Radiograph- enlarged pulp chambers, wide root canals, and loss of lamina dura, rg band that surrounds region of DEJ and pulp horn.Liver DiseaseViral Hepatitis or alcoholic liver diseaseHep A transmission through fecal contamination of food or water; mild severity and self limiting Hep B Transmitted through mucous, blood or sexual; greater morbidity & mortality; vaccine available Hep C mainly transmitted by blood; iv drug users Chronic hepatitis may occur with Hep B,C,D; Hep A & E resolve with usually no complication Bleeding tendency and lichenoid eruptions may be an issue for Hepatitis pts.-MD consult to determine liver dysfunction -Minimize the use of drugs metabolized by the liver (LAs, Analgesics, Sedatives, Antibiotics) -Universal precautions STDsViral and BacterialGonorrhea Neisseria gonorrhoeae is etiology; Many antibiotic resistant forms; discharge and pain upon urination; gonococcal stomatitis is uncommon (resembles lichen planus or herpes) Syphilis Treponema pallidum (spirochete); produces skin and mucous membrane lesions in acute phase, and bone, visceral, cardio, and neurologic disease in chronic phase; oral or genetal chancre in primary syphilis; Congenital syphilis may demonstrate dental abnormalities (Hutchinsons incisors or mulberry molars) Genital Herpes HSV types 1 & 2 (oral mainly type I & genital type 2); many infection asymptomatic; primary and recurrent types (remains latent in regional ganglion) recurrent only on attached epithelium HPV over 100 genotypes; HPV 16 & 18 have high malignant transformation rate; asymptomatic condyloma (oral or genital) Infectious Mononucleosis cause by Epstein-Barr virus (EBV); fever, sore throat, tonsillar inlargement, lymphadenopathy, malaise, fatigue, liver and spleen enlargement; oral petechiae may be seen.-If suspected disease, refer to MD -Oral lesions should be excised and submitted for biopsy -For oral herpes infection, postpone elective dental care until lesion is healing (scab phase) -Consider antivirals during prodromal stage of HSV -Delay routine dental tx for 4 wk with infectious mononucleosisG-6 PD DeficiencyInheritedMore common in African-Americans and other ethnic groups (Mediterranean, Middle East & Asian) Blockage of the hexose monophosphate shunt pathway in individuals with G-6PD deficiency allows accumulation of harmful oxidants with RBCs leading to hemolytic anemiaRecognize infection is the event most commonly triggering hemolysis 40 drugs may induce including Aspirin and acetaminophenPernicious AnemiaDeficiency of intrinsic factor, a substance secreted by the stomach parietal cells that is necessary for absorption of vit B12 likely autoimmuneOral manifestations include: -Parasthesias of oral tissues (burning, tingling, numbness) -Delayed healing (severe cases), infection, bald red tongue, angular cheilosis -Petechial hemorrhagesNo modifications detection and medical txEpilepsyIdopathic - >50% Other causes: hypoglycemia, drug withdrawl, infectionClassic Grand mal seizure aura (visual disturbance), epileptic cry, tonic phase (muscle rigidity,pulpal dilation and eyes rolling back & loss of consciousness) clonic activity (jerking movement of limbs, forcible jaw closing and head rocking), urinary incontinence-Identify pt by hx: type of seizure, degree of control, precipitating factors -Seizure managed with a ligated mouth prop at the beginning of appt -Protect pt during a seizure (turn pt to side, supine chair position, passively restrain), manage airway, and discontinue tx afterward -Recongnize gingival overgrowth caused by phenytoin (Dilantin)MethemoglobinemiaCongenital and Acquired - Methemoglobin is a form of  HYPERLINK "http://en.wikipedia.org/wiki/Hemoglobin" \o "Hemoglobin" hemoglobin that does not bind  HYPERLINK "http://en.wikipedia.org/wiki/Oxygen" \o "Oxygen" oxygen (associated with benzocaine, prilocaine and articaine)Cyanosis-like state in the absence of cardiac or respiratory abnormalities. Administration of prilocaine to patients with congenital methemoglobinemia or other clinical syndromes in which the oxygen-carrying capacity of blood is reduced should be avoided because of the increased risk of producing clinically significant methemoglobinemia. The methemoglobin reductase enzyme system continually reduces the Fe+++ to the Fe++ at a rate of .5 g/dl per hour thus maintaining a level of less than 1% methemoglobin in the blood at any given time. As blood levels of methemoglobin increase, clinical signs and symptoms of cyanosis and respiratory distress may become noticeable.Pathways -Spray benzocaine is more likely to induce -Refrain from excessive amounts LAs Management is not by administering O2, but by slow IV administration of 1% methylene blue or IV or IM ascorbic acid, which accelerates the metabolic pathways that produce ferrous atoms.Malignant HyperthermiaInherited autosomal dominant disorderTriggered by exposure to certain drugs used for  HYPERLINK "http://en.wikipedia.org/wiki/General_anesthesia" \o "General anesthesia" general anesthesia (specifically all  HYPERLINK "http://en.wikipedia.org/wiki/Volatile_anesthetic" \o "Volatile anesthetic" volatile anesthetics), nearly all  HYPERLINK "http://en.wikipedia.org/wiki/Gas_anesthetic" \o "Gas anesthetic" gas anesthetics, and the neuromuscular blocking agent  HYPERLINK "http://en.wikipedia.org/wiki/Succinylcholine" \o "Succinylcholine" succinylcholine. In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in  HYPERLINK "http://en.wikipedia.org/wiki/Skeletal_muscle" \o "Skeletal muscle" skeletal muscle  HYPERLINK "http://en.wikipedia.org/wiki/Oxidative_metabolism" \o "Oxidative metabolism" oxidative metabolism which overwhelms the body's capacity to supply  HYPERLINK "http://en.wikipedia.org/wiki/Oxygen" \o "Oxygen" oxygen, remove  HYPERLINK "http://en.wikipedia.org/wiki/Carbon_dioxide" \o "Carbon dioxide" carbon dioxide, and regulate  HYPERLINK "http://en.wikipedia.org/wiki/Body_temperature" \o "Body temperature" body temperature, eventually leading to  HYPERLINK "http://en.wikipedia.org/wiki/Blood_circulation" \o "Blood circulation" circulatory collapse and death if not treated quickly.Amide LA are not likely to trigger episodesPagets Disease osteitis deformansUnknown - chronic bone disorder that is due to irregular breakdown and formation of bone tissueElevated alkaline phospatase levels in blood Signs and symtpons: bone pain, headaches and hearing loss, increase in head size, bowing of limb or curvature of spine may occur in advanced casesBisphosphonate tx consider B-ONJ Bisphosphonate Associated ONJSuppressed bone turnover due to drug tx Inhibits osteoclastic function and induces apoptosis -Drug may remain in the body for yearsUse in tx of osteoporosis, Pagets disease and hypercalcemia of malignancy (Multiple myeloma & metastasis of breast, lung & prostate cancers) IV formulations are more likely to cause ONJ: etidronate(Didronel), pamidronate(Aredia) or zeldronic acid(Zometa)-Provide routine dental care -Atraumatic dental procedures -High risk with sx tx (especially IV Bisphos) -Consider endo vs. TE -If infection, aggressive use of systemic antibiotics is indicatedJoint ReplacementJoint guidelines from ADA & AAOSAntibiotic prophylaxis is recommended for high risk pts: -Immunocompromised/Immunosuppressed pts. (i.e. type I diabetes, RA, SLE) -First 2ys following joint replacement -Previous joint infections -Hemophilia-MD consult if necessary -Antibiotic guidelines as with IESystemic Lupus ErythematosisAutoimmune disease (unknown etiology)Discoid Lupus only affects the skin; SLE is more serious Signs and symptoms: Butterfly rash and polyarthritisMD consult due to likely corticosteroid tx and possible thrombocytopenia (abnormal bleeding) Oral lesions likely resemble lichen planus or leukoplakiaSjogrens SyndromeAutoimmune complex (EBV may be involved) Triad of clinical conditions: -keratoconjunctivits sicca -xerostomia -connective tissue disease (rheumatoid arthritis) Predominately affects womenDental management of xerostomia, glossitis, mucositis, parotid gland hypertrophy, angular cheilosis, dysgeusia (taste dysfunction) and increased caries rateLyme DiseaseBorrelia burgdorferi (spirochete)Tickborn illness signs and symptoms include: -Rash (erythema migrans) -fatigue, malaise -arthritis -neuralgia-Identify symptoms: Bells Palsy can be caused by Lyme disease TX: Referral to MD doxycycline 3wks (early stages); IV antibiotics (late stages)Basal Cell Nevus SyndromeAutosomal dominant with variable expressivity Multiple OKCs, calcification falx cerebri, and multiple cutaneous nevi establish a diagnosis. It is characterized by five major components, including multiple nevoid basal cell carcinomas, jaw cysts, congenital skeletal abnormalities, ectopic calcifications, and plantar or palmar pits. 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