medical mgmt of dental patients

8/8/2019 Medical Mgmt of Dental Patients

http://slidepdf.com/reader/full/medical-mgmt-of-dental-patients 1/17Oral Medications

Cianciola & Beach PeriodontalGroup

The Medical Management of Dental Patients


Welcome Back toAnother Great Year!


Topics of Discussion

ASA Classifications

Abx Prophylaxis

Top 20 drugs

Oral Manifestations

Drug Metabolism

Bisphosphonates


I. The ASA Classification

I – normal, healthy, ages 5-60

II – mild systemic disease w/o limits,age >60

III – moderate-severe systemicdisease, limits activities

IV – severe systemic disease,constant threat to life

V – morbid, risk of death w/ in 24hrs or w/o operation

VI – organ donor


ASA Examples

II – controlled HTN or diabetes

III – stable angina, diabetes w/

systemic sequeale IV- severe CHF, ESRD


Imagine scaling thesebabies!!




II. Antibiotic Prophylaxis (AP)


Goals of AP

To prevent post-tx microbialcomplications (local)

To diminish bacterial metastaticinfections (distant)

– Review compliments of Dr. B.C. Muzyka @ LSU


Principles of AP

Benefit>risk

Abx must be present inblood/target tissue beforeorganism entry

Loading dose of abx must be used


Principles of AP

Choice of abx based on singlemost likely organism to causeinfection

Must be a favorable cost:benefit


Potential Harm…


Potential Harm

Incr risk of abx-induced allergy

Incr risk of super infection

Selection of abx resistant micro-organisms

Encouragement of less meticuloussurgery/dentistry ?




Incidence of Bacteremia


Dental Procedures

Extractions (51-58%)

Perio surg (36-88%)

Sc/rp (8-80%)

Dental prophy (0-40%)

Endo (0-15%)


It’s All Relative….


Daily Exposure

Brushing (0-26%)

Flossing (20-58%)

Chewing (17-51%)

Irrigation device( 7-50%)

Toothpicks (20-40%)


Understanding HeartMurmurs


Heart Murmurs

Sounds produced by turbulent blood flow

Physiologic- innocent or functional-NoAbx prophylaxis required

Pathologic- risk for endocarditis- Abxprophylaxis required

Causes: stenosis- incompetentvalves, vegetations or deformities of the septa




Chain of Events

Endothelialdamage

Plateletaggregation

Fibrin deposit

Nodular sterilevegetations

Vegetationscolonized bycirculating bact→thrombosis

Replication

Enlargement of thrombosis


Bacteria

2,345 cases from1933-1987

Strep (56.4%)

Staph ( 24.9%)


Remember…It is inappropriate to

prescribe Abx w/o GoodCause!


Your Role

Ask pt if he/shehad a consult w/MD to determinetype andsignificance of murmur

It is YOUR team’sobligation todeterminewhether the ptrequires Abx

coverage


Your Role as theCaptain

If in doubt,cover the pt andthen send the pt

to his/her MD todetermine thepathology

My Role




EndocarditisProphylaxis Categories


High Risk- Abx Recommended

Prosthetic heart valves

Aortic valve disease

Mitral insufficiency

Patent ductus arteriosus

Ventricular septal defect (VSD)

Coarcation of the aorta

Previous episode of endocarditis

Surgically constructed pulmonary shunts


Moderate Risk- AbxRecommended

Patent ductus arteriosus

VSD

Primary atrial septal defect (ASD)

Coarcation of the aorta

Bicuspid aortic valve

Acquired valvular dysfunction (RF)

Hypertrophic cardiomyopathy

MVP w/regurgitation and/or thickenedleaflets


Negligible Risk- Abx NotRecommended

Isolated secundum ASD

Surgical repair of ASD

VSD or patent ductus arteriosus w/oresidua beyond 6mo

Previous CABG

MVP w/o regurgitation

Physiologic HM

RF w/o valvular dysfunction

Pacemakers and defibrillators


AHA AbxRecommendations

Amox 2g PO 1hr prior ($1.50)

Clindamycin 600mg PO

1hr ($3.88) Cephalexin 2g PO 1hr

($2.14)

Azithromycin 500mg PO1hr ($18)

Clarithromycin 500mgPO 1hr ($5.10)


How Can You Help?

Good oral hygiene reduces thelikelihood of infective

endocarditis and other bacteremias in the at risk pts




Prosthetic Joints

All pts during the 1

st

2yrs post-op Immunocompromised pts

Pts w/ co-morbidities

Previous joint infection

Hemophilia

HIV

Type I Diabetes

Malignancy


Life truly is a Beach!


III. The Top 20 MostPrescribed Drugs…


Drugs 1-10

Vicodin

Lipitor

Synthroid

Atenolol

Amoxicillan

Lisinopril

HCTZ

Furosemide

Albuterol inhaler

Alprazolam (Xanax)- anxiety


Drugs 11-20

Norvasc

Zoloft

Z-Pak

Toprol XL Cephalexin

Darvocet

Zocor

Prevacid

Ibuprofen

Triamterene;HCTZ


Heart Disease Meds

HCTZ, furosemide, triamterene =diuretics

Lisinopril- After load reducingagent (ACE inhibitor)

Atenolol- β-blocker

Norvasc, Toprol- Ca2+ channelblocker

Zocor- cholesterol lowering agent




New Medications

Why are Med Hx updates important?

There are about 20-30 new medsintroduced each year!

Pts are living longer

Pts are taking more meds

There are more than 800 generic drugs

There are more than 2,500 brand namedrugs!

DiMatteo 2006


Drug References

ADA Guide to Dental Therapeutics www.ada.org/prof/resources/pubs

Drug Information Handbook for Dentistry


Patient Expectations

Pts expect to be relatively pain-free

What amount of pts report beingdental phobic?

Only 15%

Despite new meds and techniques,% has stayed about the same for the past 15-20yrs

DiMatteo 2006


What can DentistsPrescribe?

We are mandated to prescribemeds only for conditions anddiseases w/in our scope of practice

Dentists are now writing more Rxnthan we did in the past


“The survey says…”


Moore et al. 2006 Survey

For 3rd molar extractions:

46% use general anesthesia

33% use IV conscious sedation 6% use nitrous oxide

2% use oral sedation

13% local anesthetic alone




IV. Drugs and OralManifestations

Can you hit thetarget but still notwin?


Xerostomia

Antidepressants/antipsychotics Antihypertensives

Antihistamines

Anticholinergics

Decongestants


Nonspecific Ulcerations

Antineoplastics (methotrexate)

Barbituates (Phenobarbital)

Dapsone

Salicylates

Sulfonamides

TCN

Direct contact w/ aspirin, peroxideor phenol


Lichen Planus


Lichen Planus


LP Histology

Hyperkeratosis

Band of inflammatory

infiltrate




LP Histology

Epithelium-R

CT-L

Lymphocytesattacking


Lichenoid Lesions

Allopurinol Antimalarials

Beta-blockers

Bismuth / Pepto-Bismol

Catopril (ACE inhibitor)

Carbamazepine / Tegretol

Chlorothiazide

Cimetidine / Tagament


Lichenoid Lesions

Chlorpropamide

Dapsone

Furosemide

Gold salts

Ketoconazole

Phenithiazine

Sprionolactone

Sulfonylureas

Streptomycin

Tetracycline

Tolbutamide

Triprolidine

Please tell us more!


Erythema-multiforme


Erythema-multiforme




Erythema-multiformeLike Lesions

Sulfonamides Penicillins

Barbituates

Salicylates


BMMP Lesion

Bullae

Ulcers

Pain


BMMP and the Eyes


BMMP Histology

Subepithelialclefting

Epi peels awayfrom CT

Auto Ab vs. thebasementmembrane


Pemphigoid-like Lesions

Ibuprofen

Furosemide

Catopril Clonidine (alpha2-adrenergic for HTN)

Penicillan, sulfonamides

Antimicrobials

Thiol-containing drugs


Pemphigus Vulgaris




(Insert cute picture here)


Pemphigus Vulgaris

Skin or mucosa

Large bullae,rupture, ulcers

Remissionuncommon

Can be lethal


Pemphigus Histology

Stratumspinosumpulled away

Basal cell layer still attached toCT

Intraepithelialclefting

Tombstoneappearance


Pemphigus-like Lesions

Ampicillin

Catopril

Cephalexin

Heroine

Ibuprofen

Penicillamine

Phenonbarbitol

Practolol

Propranolol

Rifampin


Lupus Autoimmune system

attacks organs or cells

Leads to damage anddysfunction

Butterfly rash


Lupus-like lesions

Carbamazepine

Chlorpromazine

Isoniazid

Lithium

Methyldopa

Penicillamine

Procainamide

Quinidine

Reserpine

Streptomycin

Thiouracils




Nonspecific Vesiculo-ulcerative Mucositis

NSAIDs, Naproxen Methyldopa

Penicillamine

Propranolol

Spironolactone

Thiazides

Tolbutamide


Oral Pigmentation Minocycline

pigmentation


Oral Pigmentation Minocycline

pigmentation


Pigmentation

Antimalarials

Bisulfan

Estrogen

Ketoconazole

Minocycline

Tranquilizers

Zidovudine


Gingival Overgrowth


Gingival Overgrowth




Post-Surgical


Gingival Overgrowth

Calcium channel blockers Cyclosporine

Phenytoin

Sodium valproate


V. Drug Metabolism


Hepatic Functions

Glucose homeostasis

Vitamin storage (D,A,K,E)

Biotransformation of compounds

Detoxification of drugs, metabolitesand hormones


Hepatic Failure

Massive liver necrosis

Cirrhosis

Functional failure w/o necrosis


Cirrhosis Etiology

3 categories we see the most:

Alcohol

Viral Hepatitis Biliary diseases




Alcoholic Liver Disease

Steatosis- fatty change (>80%)Usually asymptomatic, reversible

Alcoholic hep (10-15%)

After an acute bout of drinking

May be reversible, may progress

Cirrhosis (10-15%)

Irreversible and lethal if no liver transplant done


Alcoholic Liver Disease:How much does it take?

Males-40g Females-lower threshold

How many beers?

3 beers (15g ETOH each)

How many glasses of wine?

2 glasses (18g ETOH each)

How much liquor?

2 drinks (17g ETOH each)


This is what happens whenkids have too much!


Medical History

Important questions to ask:

Hx of jaundice?

Any liver disease in the family?

Any recent travel (parasites, hep)?

Any exposure to animals/others w/liver disease?

Sexual Promiscuity-STD, HIV

IDU or nasal drug use?

ETOH habits?

Drugs?


Don’t forget to ask aboutAcetaminophen use!

“Witch”patient is

telling thetruth?


Acetominophen InducedLiver Toxicity

Susceptibility

Chronic ETOH use

Older ageUse of other CYP-450 inducers

Nutritional status

Key events

Treatment




Acetominophen InducedLiver Toxicity

Key eventsRate of toxic metabolites >detox

Cell death via disruption of Ca2+

homeostasis

Treatment

N-acetylcysteine w/in 10hrs

Oral or IV


VI. Bisphosphonates


Where to Look for moreInformation:

AAP web site

www.perio.org


Osteonecrosis of theJaw (ONJ)

A condition observed in cancer ptswho undergo invasive procedures

Extractions

Implants


Bisphosphonates

Bone sparing drugs

Used to tx osteoporosis and bone

cancer IV tx for cancer pts to decrease

pain and fracture associated w/bone cancer


Osteoporosis

Low or decreasing bone mass

Increased risk for bone fractures

Risk factors:Smoking

Age

Medications

Systemic disease




AAP’s Position

AAP Clinical Statement onBisphosphonates

AAP Press Release on SeriousOral Post-surgical Complicationsassociated w/ IV Bisphosphonates

FDA’s statement may be viewedfrom this site, too


Who can get ONJ

Cancer pts that are:

Females

Older

Edentulous regions

Combo cancer therapy

Blood dyscrasias / metastatic disease

Anemia coagulopathy

Surgical dental procedures

Prior infection


Treatment Options

For pts on IV tx, try to avoidinvasive procedures

Try to tx pt before IV therapy starts


Bone Loss & PeriodontalDisease

A chronic bacterial infection

Releases toxins that causeredness and inflammation

Toxins damage the bone supportand may → tooth loss

The infection can travel throughthe body


Periodontal Disease andits Links

This disease has been linked to other inflammatory conditions:

Cardiovascular disease Diabetes

PTLBW babies


Review of Topics

ASA Classifications

Abx Prophylaxis

Top 20 drugs Oral Manifestations

Drug Metabolism

Bisphosphonates


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Thank you, it’s been awhale of a time!

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