Notes for Special Pa ents Clinic

Most Common Medical Emergency in Dental

Syncope Epinephrine Reac on
Allergic Reac ons Insulin Shock
Angina Cardiac Arrest
Postural Hypotension Anaphylaxis
Asthma MI
Hyperven la on Seizures

Version A

1. DISEASE OF CARIES: RISK ASSESSMENT & TREATMENT

- Cariogenic biofilm in the presence of oral status that is more pathological > protec ve leads to dental hard ssue
demineraliza on
⚪ CAMBRA (Caries Management By Risk Assessment) – treat & prevent caries by using chemotherapeu c agents,
increasing saliva flow & other things
- Root exposure: cementum demineralizes at higher pH & 2x faster than enamel.
⚪ Low salivary flow = highest risk factor for caries
- 3 greatest risk factors for caries:
1. Pathogens that cause caries (bacteria)
2. Insufficient salivary flow
3. ≥ 3 daily snacks of fermentable carbohydrates
- Chemotherapeu cs: an -bacterial (0.12% chlorhexidine, xylitol, NaOCl protocols), remineralizers (F varnish, 1.1% F toothpaste,
Ca/PO3 formula ons), alkalinizers (raise pH, counteracts acid)
⚪ 0.12% chlorhexidine gluconate (CHX)
■ Ca onic so a aches to anionic tooth + MS bacteria
■ Is released for 4-12 hrs
■ Use for 1 week/month. Rinse w/ 30 mL for 30 seconds & spit out excess.
■ Don’t rinse, eat or drink for 30 min. Separate from F products by at least 1 hr.
⚪ 1.1% NaF paste/gel
■ Remineraliza on, brush in AM/PM with paste for 2 min, spit out excess.
■ Don’t rinse, eat, or drink for 30 min. Separate from CHX product > ½ hour.
■ Ex. Prevident 500 booster heavy gel = good choice
⚪ Xylitol
■ 2 gum pieces or mints 4x/day, chew gum for 5 min only
- Caries Recall
RISK CARIES RECALL EXAM BITEWINGS RECALL
EXTREMELY HIGH 3 months 6 months or un l no new caries evident
HIGH 3-4 months 6-18 months or un l no new caries evident
MODERATE 4-6 months 18-24 months
LOW 6-12 months 24-36 months

2. GERIATRIC PATIENT CARE (> 65 yrs old)

- Geriatric degree of frailty is determined by:
1. Func onal ability
2. Cogni ve capacity
 3. Medical condi ons & related tx
- Normal aging changes explain the prevalence of some common condi ons (vs. pathology)

Organ/func on Aging Changes/Condi ons

Muscle loss - Older bodies contain more fat, less water, & less albumin
- A er 30 yrs, 1%/yr. - synthesis → different drug metabolism, more potent for ADRs
- 25% lost by 70 | 30-40% lost by 80 - Coordina on & strength ↓ → more falls
Heart Valves - New murmurs can occur
- Thicken & s ffen valves - Cardiac walls thicken & s ffen yielding delayed L ventricular filling
- Aor c & mitral valve most affected → fibrilla on → heart failure
- Chemoreceptor ac vity ↓, heart rate, sinus node, pacemaker
func on ↓
Brain - Structurally: ↓ #/branching of glial cells + synapses → reducing
- Changes @ 3 levels transmission/recep on so slower impulse spread
- Chemically: ↓ NT & receptor synthesis → memory lapses,
confusion, demen a
- Func onally: ↓ efficacy of hemosta c adj. to environment
Skin - A er 40 yrs old, subcutaneous layer thins, epidermis loses
adherence → wrinkles, purpura, fragility, skin cancer
Bone - Osteoporosis → fractures
- A er 30 yrs old, bone is lost 1%/yr.
Kidney - Renal func on: affec ng drug excre on → HTN
- Changes @ 3 levels - Urinary tract: incon nence, ↑ UTI & prostate issues
- Body fluids & acid/base balance: ↑ dehydra on
Liver - Age 30-60, 1/3 weight lost
- Blood flow ↓ by 40%
- ↓ ability to metabolize drugs
GI Tract - ↓ GI strength & lack of contrac on coordina on → more choking,
aspira ons or regurgita ons
- Stomach secretes less acid + pepsin so drugs disrupt mucosal layer
- Cons pa on & fecal incon nence

3. INFECTIVE ENDOCARDITITS
- Cardiac condi ons w/ highest risk of adverse outcome from IE = recommend AB prophylaxis
⚪ Prosthe c cardiac valve
⚪ Previous IE
⚪ Congenital heart defect (CHD)
■ Unrepaired cyano c CHD, including those with pallia ve shunts + conduits
■ Completely repaired CHD w/ prosthe c material/device during 1st 6 months a er procedure
■ Repaired CHD w/ residual defect @ site or adjacent to site of prosthe c patch/device
⚪ Cardiac heart transplant, who develop cardiac valvulopathy
- Don’t do AB prophy for: mitral valve prolapse w/ regurgita on, rheuma c <3 disease, ventricular septal defect, atrial septal
defect, hypertrophic cardiomyopathy, pacemakers
- Regimen for Dental Procedures
Situa on Agent Regimen (1 dose 30-60 min before procedure)
Able to take oral meds Amoxicillin A: 2 mg
K: 50 mg/kg
Unable to take oral meds Ampicillin or A: 2 gm IM or IV
Cephazolin K: 50 mg/kg IM or IV
Cephtriaxone A: 1 gm IM or IV
K: 50 mg/kg IM or IV
Allergic to penicillin, able to Cephalexin A: 2 gm
take oral drugs K: 50 mg/kg
Clindamycin A: 600 mg
K: 20 mg/kg
 Azithromycin A: 500 mg
K: 15 mg/kg
Clarithromycin A: 500 mg
K: 15 mg/kg
Allergic to penicillin, can’t take Cephazolin or A: 1 g IM or IV
oral meds cephtriaxone K: 50 mg/kg IM or IV
Clindamycin A: 600 mg IM or IV
Phosphate K: 20 mg/kg IM or IV

4. HYPERTENSION
- Hypertension = systolic > 140 or diastolic > 90 or using HTN medica ons.
- BP measured by turbulent blood flow (Korotkoff sounds)
- High BP prevalence ↑ w/ age: over ½ people > 65 yrs old have HTN
⚪ Over 40-70 yrs old, each incremental rise of 20 mmHg in SBP or 10 mmHg in DBP x2 the risk of CVD from
185-115/115-75 mmHg.
- Treatment Goals
⚪ BP < 140/90 for persons ≤ 60 yrs or persons at any age w/ diabetes or non-diabe c chronic kidney disease
⚪ BP < 150/90 for persons ≥ 60 yrs
- An -Hypertensive Drugs
Diure cs Thiazides (Diuril, HCTZ)
Loop Diure cs (Lasix)
K-Sparing Diure cs
Combina on
Beta Blockers Cardioselec ve (β-1): atenolol, metoprolol
Non-selec ve (β -1 & 2): propranolol, nadolol
Combina on Alpha-Beta Blockers
ACE Inhibitors Benazepril, captopril, enalapril = -pril
ARB (angiotensin receptor blockers) Losartan, = -sartan
Ca+ channel blockers Amlodipine, depridil
Alpha-1 Blockers Prazosin, = -osin

- Oral Manifesta ons are mostly due to HTN drugs → Ex. Ca+ channel blockers = gingival hyperplasia
- Ostrow Hypertension Protocol
Blood Pressure Management
S ≤ 140 NA
D ≤ 90
S = 160-141 Repeat BP x3 at 5-10 min intervals
D = 95-90 Okay to treat. Advise pt. Refer.
S = 180-161 Repeat BP x3 at 5-10 min intervals
D = 105-96 Emergency dental Tx only. Refer for consult
S = 200-181 Repeat BP x3 at 5-10 min intervals
D = 115-106 Emergency dental treatment of prescrip ons only
Refer immediately to MD/ER
S ≥ 201 Repeat. Refer immediately to MD/ER
D ≥ 116

- Use stress reduc on protocol: good pt rapport, min wai ng me, short morning apt, ensure physical comfort. If pt is anxious,
consider oral or nitrous seda on.

5. ARRHYTHMIAS
- SA node → atria contracts → AV node → BOH → PF → ventricle contracts → blood puts out
- Sinus rhythm = normal heart rhythm origina ng in SA node = 60-100 BPM
⚪ Tachycardia = rapid heart rate > 100 BPM
⚪ Bradycardia = slow heart rate < 60 BPM
 - Heart block: interrup on in normal electrical conduc on between atria & ventricles so that they beat independently
- Atrial fibrilla on: most common sustained arrhythmia (chao c heart beat)
- Stable (controlled) arrhythmia = treat as normal person
⚪ use <2 cartridge of LA w/ epi
- an bio c prophylaxis is not recommended for pt w/ pacemaker or defibrillator
- avoid electrical interferences w/ pacemaker (no ultrasonic scalers, electrosurgery close to pacemaker)
- most tx allowed if INR < 3.5

6. ISCHEMIC HEART DISEASE (CORONARY HEART DISEASE)

- Ischemic cardiomyopathy results when arteries that bring blood/O2 to the heart are blocked
⚪ May be buildup of cholesterol + plaque in arteries
⚪ May result in acute coronary syndromes like angina pectoris, MI, sudden death
- Clinical Pa erns of Angina
Class Clinical Findings Features
I No limits of ordinary ac vity Angina may occur w/ prolonged exer ons @ work/recrea on
II Slight limit of ordinary ac vity Angina may occur:
- Walking/climbing stairs fast
- Climbing > 1 flight of stairs at normal pace & in normal
condi ons
III Marked limita on of ordinary ac vity Angina may occur:
- Walking 1-2 level blocks
- Climbing 1 flight of stairs @ normal pace/condi ons
IV Unable to carry on any physical ac vity Angina may be present @ rest
w/out discomfort

- Stable Angina/Post-MI > 4-6 weeks

⚪ Have nitroglycerin available (maybe prophylac cally?)
⚪ Limited epi (2 carp = 0.04 mg) or levondordefrin
- Unstable Angina/MI < 4-6 weeks
⚪ Avoid elec ve care
- If pa ent develops angina during dental treatment
⚪ Stop procedure
⚪ Give nitroglycerin (vasodilator)
⚪ If a er 5 min, pain is s ll there → give another nitroglycerin
⚪ If a er 5 more min → give another nitroglycerin
⚪ If pain persist, assume MI in progress & ac vate EMS
⚪ Give aspirin tablet to chew & swallow.
⚪ MONA = monitor, oxygen, nitroglycerin, aspirin

7. HEART FAILURE (HF)

- Common causes of HF: Coronary heart disease/MI, HTN, cardiomyopathy, valvular heart disease, myocardi s, IE, congenital
heart disease, pulmonary HTN, pulmonary embolism, endocrine disorders (ex. thyroid disease)
- Ejec on Frac on (EF): propor on/frac on of blood pumped out the heart w/ each beat. Normal EF = 55-70%
- Clinical Manifesta on
⚪ Signs of right HF: systemic venous conges on (ex. distended neck veins, enlarged liver, peripheral edema, ascites)
⚪ Signs of le HF: pulmonary edema (dyspnea)
- Dental management
⚪ For undiagnosed pts w/ HF symptoms, defer elec ve care & prefer to MD.
⚪ For pt w/ diagnosed HF: treat class I-II while avoiding elec ve care for Class III-IV
⚪ Semi-supine or upright chair posi on
⚪ Drug considera ons
■ If taking digitalis (treat CHF/arrthymias), avoid vasoconstrictors. Avoid erythromycin & clarithromycin (can ↑
toxicity).
■ If taking NS β-blocker, use vasoconstrictors cau ously
■ Avoid NSAIDS
8. CHRONIC RENAL FAILURE (CRF)
- Clinical stages of CRF
⚪ Diminished renal reserve – nephrons destroyed, asymptoma c, elevated crea nine
⚪ Renal Insufficiency – homeostasis is preserved but nephron destruc on has symptoms of mild azotemia (↑
BUN/crea nine), polyuria, nocturia, impaired ability to concentrate urine
⚪ Renal failure (ESRD) - 90% of nephrons destroyed, loss of homeostasis → uremia/uremic syndromes
- CRF Lab
⚪ Crea nine clearance, glomerular filtra on rate (GFR), BUN, serum crea nine = most important test for kidney func on
⚪ Dialysis need is tracked by crea nine test & GFR
- E ology: any condi on that destroys nephrons = diabetes mellitus > HTN > chronic glomerulonephri s > polycys c kidney
disease, systemic lupus, neoplasms, AIDS nephropathy, gene c/environmental factors
- Clinical signs: reten on of urinary products → interference w/ endocrine/metabolic func on, infec on & bleeding
- Oral manifesta ons – mostly due to dialysis
⚪ pallor of oral mucosa = anemia
⚪ Bone: osseous changes of the jaw → triad of loss of lamina dura, ground glass-like demineralized bone, localized
radiolucent jaw lesions (central giant cell granulomas)
⚪ Gingiva: Dilan n-like enlargement due to meds, ↑ suscep bility to gingivi s/periodon s
- Medical management
⚪ Conserva ve care (no dialysis): ↓ reten on of nitrogenous waste product, control HTN, & fluid/e- imbalances
■ Tx: diet modifica ons, tx of associated condi ons
⚪ Dialysis: used when pt has uncontrolled azotemia, mostly hemodialysis
- Dental management for conserva ve pa ents
⚪ Consult with MD for ESRD pa ents!
- Dental management for hemodialysis pa ents
⚪ Ini ally & periodically MD consult about risk of endarteri ts (artery inflamma on) & IE + need for prophylaxis
⚪ CHF & dialysis pts: ~ 40% have CHF, needs to be stable for dental tx
⚪ Perform major surgical/bleeding procedures before next dialysis. Consult w/ MD if unable to treat > 6 hours a er
dialysis
- Do short recalls, eliminate infec on, stress OHI, avoid extensive crown & bridge restora ons in ESRF if pt is unstable, best to
perform dental care on day a er dialysis (less fa gue, heparin has worn off), protect shunt arm.

9. LIVER DISEASE
- Hepa s A (HAV): fecal/oral route
- Hepa s B (HBV): acute infec on that can resolve w/ tx (90%)
- Hepa s C (HCV): blood born infec on, >60% associated w/ IV users (IDUs), can develop into chronic state (75-85%) → cirrhosis,
liver failure, HCC
⚪ Which one is chronic & cancerous? HCV AND ______
- Hepa s D (HDV): coinfec on/super-infec on to HBV
- Lab Tests – An bodies
HAV HBV HCV HDV HEV
An -HAV IgG HBsAg → (+) = infec ous An -HCV → previous infec on An -HDV An -HEV
An -HBs (HBsAb) → recovery/vaccinated HCV RNA → infec ous HD-Ag
An -HBc → acute, persistent infec on or
nonprotec ve previous infec on
➔ Usually in chronic infec ons, (+) HBsAg
HBeAg → infec ous
An -HBe → clearing/cleared infec on

- Oral manifesta ons: lichenoid erup ons (due to meds)

- Dental Management
⚪ HBV/HCV carrier – Med consult
■ Avoid drugs metabolized by liver or use reduce dose
■ Use up to 3 cartridge of 2% lidocaine (120 mg)
⚪ Chronic ac ve – monitor lab values
■ PT/INR > 3.5 → postpone surgery or consider Vit K injec on
- Alcoholic Liver Disease
 ⚪ Oral manifesta ons:
■ Impaired gustatory func on leads to malnutri on → glossi s, tongue papillae loss, angular/labial cheili s
■ Thrombocytopenia = bleeding tendency
■ Sweaty, musty odor to breath
■ Sialadenosis, glossi s, angular cheilosis, bruxism, dental a ri on, xerostomia
■ ↑ oral cancer risks
⚪ Dental Management
■ Untreated alcoholic liver disease = no elec ve tx, MD consult
■ Lab test before invasive procedures: CBC w/ differen als, AST, ALT, platelet thrombin me, PR/INR

10. SOLID ORGAN TRANSPLANT

- Organs: heart, kidney (most common), liver, lungs, pancreas, intes nes
- Triple drug immunosuppression therapy = best results
- Total body irradia on (1000cGy) = most effec ve means to prepare a bone marrow gra recipient
- Ex. of Immunosuppressive Agents for Use in Early Post-Transplant Period
AGENT CLASS MOA
PREDNISONE cor costeroid Blocks cytokine gene transcrip on
CYCLOSPORIN Calcineurin inhibitor Inhibits IL-2 gene transcrip on
Reduces ac va on of T-cells

- Signs of over-immunosuppression in post-transplant pt

⚪ Cushingoid reac ons (cor sol)
⚪ Addison reac ons (low hormones)
- Oral manifesta ons
⚪ Gingival overgrowth (due to meds like cyclosporine, nifedipine)
⚪ Viral infec ons (ex. HSV, EBV)
⚪ Bacterial & fungal infec ons
⚪ Gra vs Host Disease (GVHD) = complica on of hematopoie c cell transplant (bone marrow).
■ Clinically looks like lichenoid inflamma on/lichen planus.
⚪ Salivary hypofunc on
- An -microbial medica ons - need AB prophylaxis
- Dental management
⚪ Very ill pt w/ ESRD = postpone dental tx
⚪ Dental consulta ons before organ transplant = rule out sources of dental infec on
⚪ Post-transplant considera ons
■ Immediate post-transplant period (transplant to when gra ssue func ons properly)
⦁ No elec ve dental tx for 1st 6 mths post-transplant. Emergency tx only.
⚪ Stable post-transplant → Elec ve dental tx a er MD consult
⚪ Post-transplant chronic rejec on: emergency tx only

11. ANTI-COAGULANT & ANTI-PLATELET DRUGS

- Normal hemostasis: trauma → coagula on cascade, extrinsic pathway
(rapid reac on), intrinsic pathway (slower reac on)
- Co-morbid condi ons that contribute to ↑ bleeding: liver disease, kidney
disease, tumor, bone marrow failure, chemotherapy, autoimmune disease
- An -coagulants = inhibit clo ng factor produc on
⚪ Warfarin/Coumadin – antagonizes Vit K produc on → interferes
w/ synthesis of coagula on factors 2 (prothrombin), 7, 9, 10.
⚪ Prothrombin me (PT) = me for fibrin forma on, extrinsic
pathway | INR = correc on for difference in sensi vity of
thromboplas n reagents
■ Recommend INR = 2-3 for prophylaxis & tx
⚪ Pt on an -coagulant therapy can undergo minor dentoalveolar
surgery w/out discon nuing an -coagulants
■ INR < 3.5 (within 24 hrs. of procedure)
■ No associated aggrava ng condi ons (ex. an bio cs, liver/kidney disease)
 ■ if INR > 3.5, refer to MD for adjustment of meds & delay dental tx 2-3 days if dosage of an -coagulants is
reduced
- An -platelet agents = inhibit platelet aggrega on
⚪ Aspirin: irreversible effect for platelet life, 7-10 days
⚪ NSAIDS: reversible effect, limit to drug dura on
⚪ If bleed me < 10 min, most surgeries can be performed
- Dental manifesta ons
⚪ Med consult, request PT/INR level (for Warfarin)
⚪ Contact pt w/in 24 hrs. following procedure

12. ASTHMA
- Asthma = chronic inflammatory respiratory disease, recurrent episode of dyspnea/cough/wheezing following exposure to
precipita ng factors
⚪ Termina on of a ack is accompanied by produc ve cough w/ thick stringy mucus
- Status asthma cus (severe, prolonged > 24 hrs asthma a ack)
- Medical Management
Classifica on Findings Drug management
Mild Intermi ent < 2 days/week None or short ac ng β-2 agonist PRN
Intermi ent Brief exacerba ons, good exercise tolerance, asymptoma c
between
FEV1 > 80% predicted
Mild Wheezing 2-5 days/week Low dose inhaled cor costeroids or
Persistent A ack affects sleep/ac vity, limited exercise tolerance, other an -inflammatory PRN
FEV1 > 80% predicted Short ac ng β-2 agonist
Moderate Daily symptoms of wheezing Low-med dose inhaled cor costeroids
Persistent Daily use of short-ac ng β-2 agonist, affects sleep/ac vity, ER Short ac ng β-2 agonist
visits
FEV1 60-80% predicted
Severe Frequent exacerba on/con nuous symptoms, can’t exercise High dose cor costeroid + long ac ng
Persistent FEV1 < 60% predicted bronchodilator + oral cor costeroids
Short ac ng β-2 agonist
- Medica ons
⚪ Primary agents of choice: an -inflammatory
■ Cor costeroids inhalants: flu casone, triamcinolone
■ Leukotriene receptor inhibitors: montelukast, zafirlukast
■ Mast cell stabilizers
⚪ Secondary agents: bronchodilators
■ Theophylline (Theo 24)
■ β-2 adrenergic agonist (albuterol)
■ Methylxanthines
■ An -cholinergic drugs
- Oral Manifesta ons
⚪ Mouth breathing = ↑ upper anterior + total anterior facial height, higher palatal vaults, greater overjets, more crossbite
prevalence
⚪ Β-2 agonist ↓ salivary flow by 20-35%
- Pre-treatment assessment: STABILITY
⚪ Mod-severe asthma: prophylaxis w/ inhaler before apt
⚪ Drugs to avoid: aspirin-containing medica ons, NSAIDS, narco cs, barbiturates
■ If taking theophylline, avoid macrolide AB & discon nue cime dine 24 hrs before IV seda on
⚪ Use anxioly c & stress reduc on: nitrous, diazepam, hydroxyzine (an -histamine + seda ve)
- If asthma a ack occurs, act immediately → stop procedure, remove rubber dam →give short-ac ng bronchodilator + O2
⚪ If no relief, subQ epi (1:1000) 0.3-0.5 mL, repeat inhaler & epi q5 min as needed
⚪ DO NOT give subQ an -histamine

13. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 - Cig smoking = most important causa ve factor
- Clinical manifesta ons
⚪ Chronic bronchi s – airflow obstruc ons on I/E, thickening of bronchial walls w/ inflamma on + mucous cell
enlargement + globet cell hyperplasia → narrowing of small airways
■ Chronic cough + phlegm, diffuse wheezing due to respiratory distress, use of accessory muscles for
respira ons, tachypnea
■ “Blue Bloater” due to liver enlargement, cyanosis, ascites, cor pulmonale
⚪ Emphysema – obstruc on from destruc on of alveolar walls by inflamma on + release of elastase by neutrophils →
enlargement of air spaces distal to terminal bronchioles + loss of elas c recoil = compromised expiratory flow
■ “Pink Puffer” – more effort to exhale, nonproduc ve min cough
- Very severe COPD = respiratory failure or signs of HF may develop, impaired/worsening symptoms
- Medical Management
⚪ Drugs (reverse tx line of asthma)
■ 1st line: Inhaled bronchodilators (β-2 agonist), an -cholinergic (ipratropoium bromide)
■ 2nd line: inhaled cor costeroids combo w/ long-ac ng β-2 agonist
■ 3rd line: theophylline combo w/ inhaled bronchodilators (severe disease – narrow threp c range)
■ Systemic cor costeroids
- Oral manifesta ons: no direct connec on between oral disease + COPD
- Dental Management
⚪ Modify rubber dam as needed to avoid possible aspira ons/triggers + not obstruct air flow
⚪ Careful use of powder products
⚪ Use pulse oximeter to monitor O2 satura on
⚪ Consider low-flow (2-3 L/min) supplemental O2 when O2 satura on drops < 91%. Do not give O2 @ higher concentra on
than room air.
⚪ If pt presents w/ ambulatory O2, check O2 levels & plan apt length accordingly + don’t turn up or O2 at higher [C]
⚪ Don’t use nitrous w/ severe COPD
⚪ Low dose oral diazepam may be used
⚪ Avoid barbiturates, narco cs, an -histamines, an -cholinergic
⚪ Avoid macrolide an bio cs (erythromycin, clarithromycin)
⚪ Outpa ent general anesthesia is contraindicated

14. TUBERCULOSIS
- Bacteria (Mycobacterium tuberculosis), most commonly affects lungs
- Transmission: airborne & infec ous for hours
⚪ Take 2-8 weeks a er infec on for person’s immune system to react & could be latent infec on
⚪ 90% of people infected w/ TB never develop ac ve disease
⚪ 10% develop ac ve disease → 50% w/in 2 years, 50% years later
- High risk for TB infec on = HIV, immunocompromised from systemic condi ons (ex. diabetes, drugs like steroids, aging), OH/IV
drug users
- Medical management
⚪ Tx takes 6-9 months
⚪ When sputum smear turns (-) (w/in 3-6 mths), the pt. isn’t infec ous
- Oral lesions/ulcers (rare) most common on tongue
- Dental management
⚪ Once status is verified, tx as normal
⚪ If pt has ac ve TB, only emergency tx using (-) pressure special isola on rooms un l pt is on medica ons, has consistent
(-) sputum samples, & no produc ve cough
- Greatest risk = tx of pt w/ undiagnosed ac ve TB

AEROSOL TRANSMISSIBLE DISEASE (ATD) POLICY

- USC doesn’t perform dental tx on pt w/ aerosol transmissible disease (ATDs), which includes TB, chicken pox (varicella), measles,
SARS, diphtheria, mumps, pertussis/whooping cough, meningococcal disease, influenza (NOT EBOLA)
- Screening Pt with ATDs:
⚪ Rou nely review Mx history & if pt. has symptoms/history of TB
⚪ Observe & ques on if pt. has symptoms of produc ve cough, night sweats, fa gue, malaise, fever, unexplained weight
 loss
⚪ Isola ng pt. w/ suspicious symptoms → reschedule, refer out, etc.
⚪ Inform pt. that they will be asked to wear surgical mask to protect others while in dental school & on the way to referral

15. GUIDELINES FOR TX OF ADULT/PEDS HIV PATIENTS

- Hemophilia can be classified as an autoimmune infec on. HIV is not AUTOIMMUNE
- USC needs CD4 count, viral load, neutrophils, platelet count
⚪ viral load doesn’t affect dental tx but indicator of poten al resistance of virus to meds & possible non-adherence to
prescribed meds
- Important Lab Values
⚪ CD4 (T4) Count > 200 (adults) or > 50 or 15% (kids)
■ in children < 5, CD4 % is preferred b/c of age-related CD4 changes
■ even pt w/ severely diminished CD4 levels may tolerate defini ve dental tx rather than pallia ve
■ < 200 = AIDS
⚪ Viral load (HIV-1RNA) < 50 if on HAART
■ Copies/mL of virus in the blood
■ If VL < 10,000 copies/mL, disease is considered by progressing slowly
⚪ Platelets > 60,000 (adults) or > 75,000 (kids)
⚪ Absolute Neutrophil Count > 500 or >20%
■ If below under 500, prescribe prophylac c an bio c from the AHA regimen prior to invasive procedures
- Pt on ART therapy or part of grants need frequent lab values: every 6 months or less, depending on the cri cal value
- HIV/AIDS Medica ons
⚪ ART therapy, started due to:
■ CD4 < 500 w/ concurrent viral load > 1000
■ AIDS-defining illness
■ HIV-associated nephropathy
■ Co-infected w/ HBV
■ Pregnant to prevent transmission to fetus
⚪ Pt w/ opportunis c infec ons might be on Bactrim (for pneumocys s pneumonia) + Acyclovir (herpe c infec on)
- Most common AIDS defining condi ons – NOT HEP B
⚪ CMV disease or CMV rhini s (w/ loss of vision)
⚪ Herpes simplex: chronic ulcers (>1 mth dura on) or bronchi s, pneumoni s, or esophagi s
⚪ Kaposi sarcoma
⚪ Burke lymphoma
⚪ Lymphoma, primary, of the brain
⚪ Mycobacterium TB
⚪ Pneumocys s pneumonia
⚪ Was ng syndrome a ributed to HIV
- Pts with advance stages of HIV/AIDS should get immediate emergency & preven ve dental care, defini ve care should be
case-based

16. ARTHRITIS & PROSTHETIC JOINTS

- Osteoarthri s (OA): degenera ve joint disease affec ng car lage that covers end of bones in joint → pain & loss of movement
⚪ Most prevalent type, affec ng > 60 yrs old
- Rheumatoid Arthri s (RA): autoimmune, chronic progressive systemic inflamma on process in synovial membrane of joints →
destruc on of ar culator car lage, ligament, tendon, bone & other organs
⚪ Any age, peak @ 40-60 yrs old, 3 female:1 male ra o
- Clinical Manifesta ons: OA VS RA
Symptoms Signs
OA Pain & s ffness; 1-2 joints @ a me Boney enlargement, limited movement, tenderness
Poor correla on w/ radiographs Crepitus sound w/ jaw movement
Morning s ffness ~ < 15 min X-ray: narrow joint space, sclerosis, cysts
Pain ↔ weather changes Signs of mild inflamma on
No Systemic involvement
RA Mul ple symmetric joints involved Warm, swollen joins
Morning s ffness ~ > 1 hr Joint deformity, erosions
 Periods of remission/ worsening Can present w/ swan fingers
Systemic manifesta on: fa gue, weakness, malaise

- OA can affect TMJ in individuals > 40 yrs old vs TMJ is involved in 45-75% RA pa ents
- Dental Management
⚪ OA
■ ↑ bleeding (pt using aspirin, NSAIDS)
⚪ RA
■ Same considera ons for OA
■ Pts on cor costeroids may have adrenal suppression
■ Side effects of DMARDs (disease modifying an -rheuma c drugs) = immunosuppression, anemia, ↓ platelets,
↓ WBC, impaired liver, ↑ bleeding
■ Get PR/INR, PTT, liver func on tests
- An bio c prophylaxis for pts w/ joint replacements
⚪ In the absence of reliable evidence linking poor oral health to prosthe c joint infec on → maintain good oral hygiene
⚪ 2013: insufficient evidence that AB use for pt w/ joint replacement works → get med consult for pt w/ compromised
immune systems
⚪ Comorbidi es include:
⦁ Immunosuppressed
⦁ Drug-induced immunosuppression
⦁ Previous prosthe c joint infec ons
⦁ Hemophilia
⦁ HIV
⦁ Diabetes – insulin dependent or poorly controlled diabetes
⦁ Malignancy
⦁ Mega-prosthesis
- Prophylaxis should be considered for placement of ortho bands + intralignmentary injec on of LA into gums near jaw
- Don’t do AB prophylaxis for restora ve or LA injec on (non-intralignmentary)
- Suggest an bio cs:
⚪ Amoxicillin, Cephalexin, or Cephradine = 2 g
⚪ Allergy to penicillin → clindamycin = 600 mg
⚪ Can’t take oral meds → cefazolin 1 g or ampicillin 2 g IV or IM
⚪ Can’t tale oral meds + allergy to penicillin → clindamycin 600 mg IV

17. MEDICATION-RELATED OSTEONECROSIS OF THE JAW (MRONJ)

- Pt must present w/ all of the following for MRONJ:
⚪ Current/previous tx w/ an -resorp ve or an -angiogenic agents
⚪ Exposed bone or bone that can be probed through an I/E fistula in maxillofacial region that has persisted > 8 weeks.
⚪ No history of radia on therapy to jaw or obvious metasta c disease to jaw
- IV Bisphosphates (BP): an -resorp ve meds to manage condi ons like hypercalcemia of malignancy, skeletal-related events
involving bone metastasis in solid tumors like breast/prostate/lung cancer, and ly c lesions (ex. mul ple myeloma). Some also tx
osteoporosis
- Oral bisphosphate: tx of osteoporosis/osteopenia
- RANK Ligand Inhibitor (denosumab): an body against RANK ligand → inhibits osteoclast ac vity
- An -angiogenic Agents: interfere w/ new blood vessel forma on by binding to various signal molecules to disrupt cascade
⚪ Effec ve against GI tumors, renal cell carcinoma, neuroendocrine tumors, etc
- Pathophysiology
⚪ BP/denosumab - ↑ apoptosis leading to ↓ bone resorp on + remodeling
⚪ ONJ only occurs in alveolar bone of max & man
■ A er tooth extrac on, pt. on oral BP = 0.5% develop ONJ while pt. on IV BP = 1.6-14.8%
- Dental management → Necro c bone removed & recontour always
Medica ons Dura on Risk Factor Recommenda ons
Oral BP < 4 yrs NA No altera ons
Oral BP < 4 yrs Cor costeroids/an -angiog Discon nue at least 2 mths before surgery
enic tx concurrently An -resorp ve not restarted un l osseous healing occurs
(Oral BP tends to stay in the bone for a long me)
 Oral BP > 4 yrs w/ or w/out concomitant tx Discon nue 2 mths before surgery

An -resorp ve not restarted un l osseous healing occurs

About to ini ate IV NA Cancer Delay un l dental health is op mal:
an -resorp ve or - Extract unrestortable teeth
an -angiogenic tx - Extrac on sites mucosalized or osseous healing
for cancer therapy Prophy, CAMBRA, restora ve, look @ dentures for trauma, OHI

ANTIBIOTIC PROPHYLAXIS IF ALLERGIC TO PENICILLIN

AMOXICILLIN 500 MG TID PER 14 DAYS Clindamycin 300 mg TID per 14 days
Azithromycin 250 mg QD per 10 days

Staging & Treatment Strategies of MRONJ

At Risk Category: no exposed bone in pt tx w/ oral/IV BP Pa ent educa on
Stage 0 Systemic management using pain + AB
Stage 1: exposed/necro c bone, asymptoma c (NO PAIN), no An -bacterial mouth rinse
infec on Clinical follow up + pt. educa on
Stage 2: exposed necro c bone w/ infec on as evidenced by pain Systemic tx w/ broad spectrum oral AB
+ erythema in region w/ possible pus discharge An bacterial mouth rinse
Pain control (no pain = stage 1)
Superficial debridement to relieve so ssue irrita on
No pa ent educa on!
Stage 3: exposed necro c bone w/ infec on, pain, & one or more An -bacterial mouth rinse
of: AB therapy
- Pathological fracture Surgical debridement/resec on for longer term pallia on of
- Extra oral fistula infec on/pain
- Osteoly c extending into inferior border

USC CLINICAL & THERAPEUTIC PROTOCOL FOR BISPHOSPHONATE

Risk assessment:

- Previous ONJ history, exposed bone

- Comorbid condi on
- Undergoing dental procedures or having ill-fi ng dentures that expose jaw bone to microbial
- IV BP = auto high risk
- Protocol: Pts taking BP, w/ history of BP use, or about to start BP. Before extrac on:
⚪ chlorohexidine mouth rinse 0.12% (3x/day) 1-week pre-op
⚪ Systemic an bio cs regimen 3 days’ pre-op (amoxicillin 500 mg QID or clindamycin 300 mg BID)
⚪ Nysta n mouth rinse regimen (3x/day) 1-week pre-op
- Protocol: Pt w/ ac ve localized ONJ lesion
⚪ Early stage lesion – chlorohexidine rinse + Nysta n rinse un l lesion resolves
⚪ Advance stage lesion – surgical and/or systemic an bio cs

CONSENT OR OMFS FOR PTS WHO HAVE RECEIVED BISPHOSPHONATES DRUGS

- Osteonecrosis from BP = smoldering, long-term, destruc ve process in the jaw bone

- BP injectable (IV) includes: Zometa (zoledronic acid) + Aredia (pamidronate disodium)
- Oral BP includes: Fosamax (alendronate) + Actonel (risedronate Na) → less potent

18. CANCER THERPAY

- Oral manifesta on depends on protocol aggressiveness; most chemotherapies cause mucosi s (radia on-induced cell death)
⚪ Radia on total dose > 6000 cGy = most mucosal reac on, ↑ risk of osteoradionecrosis (ONR) → avoid invasive dental
work
- Pt on chemotherapy/radia on therapy
⚪ Salivary gland dysfunc on (dry mouth)
 ⚪ Poor healing
⚪ ↑ risk of infec on due to mucosi s
⚪ Neurotoxicity
⚪ Taste dysfunc on
⚪ Recurrent aphthous ulcera ons
⚪ Weight loss & malnutri on
- Perform OS at least 2 weeks before star ng radia on therapy & at least 7-10 days before myelosuppressive chemotherapy begins
- Allow adequate healing before radia on therapy or consider hyperbaric O2 therapy
- Oral Care during Chemo/radia on therapy
⚪ Med consult, only emergency dental tx
⚪ Reduce use of removable appliances
⚪ Mucosi s prophylaxis + tx → OHI + avoid irritants/cariogenic diet (acid, spice, high T foods)
⚪ If excessive bleeding → damp gauze to wipe teeth & so ssues
⚪ Chlorohexidine rinse 0.12%
⚪ Xerostomia pa ents need neutral pH 1% F gel brush on or F tray + diet counseling
■ Saliva subs tutes or oral lubricant, non-OH rinse
⚪ Pt on chemotherapy
■ Blood work 24 hrs. before appt → neutrophils > 1000, platelets > 50000, no abnormal clo ng factors

19. DIABETES MELLITUS

- Classifica ons
⚪ Type I – β cell destruc on/defec ve → absolute insulin deficiency (immune related or idiopathic)
⚪ Type 2 – insulin resistance, rela ve insulin deficiency, non-autoimmune
- Diagnos c Criteria for DM
SITUATION RANDOM PLASMA GLUCOSE FASTING BLOOD GLUCOSE ORAL GLUCOSE TOLERANCE TEST
(COUPLED W/ DM SYMPTOMS – (NO CALORIE INTAKE > 8 (2 HRS POST-MEAL)
POLYURIA, POLYDIPSIA, HRS)
UNEXPLAINED WEIGHT LOSS)
NORMAL <200 mg/dL < 110 mg/dL < 140 mg/dL
ABNORMAL ≥ 200 mg/dL ≥ 126 mg/dL ≥ 200mg/dL

- Glycosylated hemoglobin (HbA1c) > 6.5% = abnormal (normal = 4-6%)

⚪ An bio c prophylaxis for high risk (HbA1c > 11-12%)
- Complica ons:
⚪ Macrovascular – Heart (CHD, CHF)
⚪ Microvascular
⚪ Neuropathy (>50% of diabetes) – neuropathic pains (ex. diabe c neuropathy, burning mouth)
- Metabolic complica ons of DM
⚪ Hyperglycemia (diabe c ketoacidosis) – chronic, slowly progressive
■ Cause: too much food, deficient insulin, too li le meds, illness, stress
■ Coma (blood glucose = 300-600 mg/dL)
⚪ Hypoglycemia – acute, rapidly progressive
■ BG < 45 mg/dL
■ Insulin shock – seizures/coma (plasma glucose ≤ 25 mg/dL)
- Diabetes in elderly → diabe c “shock” (o en in those who aren’t known to be diabe c)
⚪ Shallow respira on
⚪ Hypotension (thread pulse)
⚪ Hyperosmolar, hyperglycemic, non-keto c coma
- Medica ons
⚪ 2nd gen sulfonylureas: ↑ insulin secre on (glipizide, glyburide)
⚪ Biguanides: less liver glucose produc on (me ormin)
⚪ Α-glucosidase inhibitor: slow carb diges on
⚪ Thiazolidinediones: ↑ ssue insulin sensi vity
⚪ Megli nides: more pancrea c insulin secre on
- Oral Manifesta ons: burning/pain in oral ssues, poor healing, salivary hypofunc on, ↑ candida
- Dental Management
 ⚪ Check random blood glucose @ appt date → 70-200 mg/dL = well controlled | > 200 = emergency tx only

PROTOCOL FOR REQUESTING BLOOD TEST OF DM PTS FROM SPC

- No test provided in SPC for new pa ents (need MD consult)

- If pt previous HbA1c < 7%, labs for stable pts done x2/year. If HbA1c > 7%, pt will require lab every 3 months.

20. ADRENAL INSUFFICIENCY

Cortex Z glomerulosa Aldosterone (MS) Mineriosteroid
NaCl + water balance (renal distal tubules)
Z fasciculate Cor sol (GC) An -inflammatory, ↓ bone forma on + muscle mass, ↑
blood glucose + GFR
Z re cularis Androgen Sex
Medulla Epinephrine ↑ cardiac output
Norepinephrine ↑ arterial P + peripheral resistance

- Clinical Manifesta ons: INSUFFICIENCY

⚪ Primary Adrenal Insufficiency (Addison’s Disease) – cortex destruc on
■ Adrenal crisis – stress → medical emergency
⦁ Signs/symptoms: sunken eyes, profuse swea ng, hypotension, weakness, headache, dehydra on,
arthralgia (joint pain), hypernatremia (low blood Na) (NOT HYPERTENSION)
■ Lab test = ↑ K +BUN, ↓ Na + glucose, mild anemia
⚪ 2ndary Adrenal Insufficiency – hypothalamic/pituitary disease or long-term cor costeroid use
- Clinical Manifesta ons: HYPERFUNCTION
⚪ Cushing’s Syndrome - ↑ cor sol
■ Insulin resistance, DM, HF, osteoporosis
- Oral Manifesta ons:
⚪ Primary insufficiency = pigmenta on of mucosa + skin
⚪ 2ndary insufficiency = delayed healing + infec on suscep bility
- Dental management – if cor costeroid was taken w/in 2 weeks → update status/stability → consider ACTH or CRH test

21. THYROID DISEASE

- Thyroid = thyroxine (T4) + triiodothyronine (T3), regulated by HPT axis
- Autoimmune disease → TH overproduc on (thyrotoxicosis) vs hormone deficiency (hypothyroidism)
⚪ Uncontrolled hyperthyroidism → Thyrotoxic Crisis (thyroid storm)
- Thyroid Hyperfunc on – 85% Graves’ Disease
- Thyroid Hypofunc on – Hashimoto’s thyroidi s (immune system a acks gland)
- Oral complica ons
⚪ Hypothyroidism = gingival hyperplasia, hypercholesterolemia, what are common symptoms??
⚪ Hyperthyroidism = osteoporosis (adults)

22. PREGNANCY

1st Trimester 1-12 weeks Fetal organ forma on + differen a on

Most suscep ble to teratogen
Emergency only (no elec ve tx)
2nd Trimester 13-24 weeks Fetal growth + matura on
Safest period for dental tx
3rd Trimester 25-40 weeks Fetal growth
Concern = risk to birth process/comfort of pregnancy

- Oral Manifesta ons:

⚪ Pregnancy gingivi s: caused by hormonal/vascular changes, ↑ circula ng estrogen = ↑ capillary permeability
⚪ Pregnancy granuloma: (~ 5% women) – max anteriors, rapid growth
 ■ Tx: Sc/RP, excision if large/bleeds easily
⚪ Other problems: excessive saliva on, tooth mobility, loss of alveolar Ca+, teeth demineraliza on/erosion (vomit)
- Dental management
⚪ No elec ve dental tx during 1st trimester (1-12 weeks). 2nd-3rd trimester = be er
⚪ No radiographs during 1st trimester. A erwards, only as needed + lead apron/collar
⚪ Advance pregnancy (3rd trimester) → no supine posi on for long me period (avoid supine hypotensive syndrome,
obstructed vena cava/aorta from fetus)
An bio cs to Avoid during Pregnancy Analgesics to Avoid during 3rd Trimester
Doxycycline May cause delivery problems
Tetracycline - aspirin, ibuprofen, naproxen
- accumulates in bone & cheletes Ca+, Cause neonatal respiratory depression/opioid withdrawal
inhibits bone growth, discolor teeth - codeine, hydrocodone, oxycodone
Erythromycin (estolate form) Seda ve/anxioly cs (diazepam, A van), risk D
Vancomycin - can cause oral cle w/ long exposure
No nitrous for 1st trimester
No NSAIDS + aspirin during 3rd trimester

TREATMENT GUIDELINES FOR PREGNANT PATIENTS

- MD consult needed:
⚪ Co-morbid condi on
⚪ Use of nitrous oxide
⚪ Anesthesia other than LA (ex. IV seda on, nitrous, GA)
- Clinical protocol
⚪ Delay amalgam removal un l a er pregnancy or weaning if rubber dam + high-speed suc on can’t be used
- Don’t use: erythromycin esolate, tetracycline, NSAIDS (1st, 3rd trimester)

23. PARKINGSON’S DISEASE

- Affects nerve cells controlling muscle. Characterized by:
⚪ Loss of 80% pigmented cells in substan a nigra
⚪ ↓ dopamine
⚪ Eosinophilic inclusions (Lewis bodies)
⚪ Same Ach amount
- Clinical manifesta on: TRAPP (tremor, rigidity, akinesia, postural instability, psych status
- One ques on → which statement is false?

24. DEMENTIA
- Aging disease, prevalence = 7% at 60 yrs old, 40% by 85 yrs old

25. ALZHEIMER’S DISEASE

- Most common form of demen a (50-70%)
- 7th leading cause of deaths in the US → Once diagnosis, life span = 8-10 yrs
- One ques on → which statement is false?

26. DEPRESSION & BIPOLAR DISORDER

- Clinical manifesta ons
⚪ Major depressive disorder (MDD) – pt must have
■ Depressed mood or loss of interest/pleasure AND
■ 4 of the following in 2-week period:
⦁ Significant weight loss/gain, appe te change
⦁ Insomnia or hypersomnia nearly daily
⦁ Fa gue or energy loss daily
⦁ Psychomotor agita on/retarda on daily
 ⦁ Feelings of worthlessness/guilt
⦁ Inability to think or concentrate
⦁ Recurrent death/suicide thoughts
■ Usually last 8-9 mths
⦁ 50-80% of people who had MDD will have another one
⦁ 20% will have subsequent manic → bipolar
⚪ Bipolar Disorder – 1 manic episode
■ Reoccurring mania & depression or mix
■ Manic episode: elevated mood, expansive (enthusias c) or irritable
■ Men are more manic while female are more depressive
- Medical Management – 80% psychotherapy, meds or both
MOA Adverse Effects Serious Adverse Effects
Tricyclics Inhibit reuptake of Dry mouth, nausea, Tachycardia, arrhythmias, MI, stroke, suicide < 24 yrs
norepinephrine + 5-HT vomit old
SSRIs Selec ve serotonin reuptake Dry mouth, nausea, Hypothyroidism, suicide < 24 yrs old
inhibitor vomit, diarrhea

Zolo | Prozac (be er

tolerated but expensive)
SNRIs Serotonin-norepinephrine Dry mouth, nausea, Hypertensions, suicide < 24 yrs old
reuptake inhibitor vomit

Cymbalta
MAOIs Monoamine oxidase inhibitor
Inhibits MAO Type A/B
A = an -depressant effect
Dry mouth, nausea, Peripheral edema, anemia, leukopenia,
vomit agranulocytosis, thrombocytopenia, suicide < 24 yrs
old

⚪ Tricyclics an -depressants: cau on in cardiac pts → risk of atrial fibrilla on, atrial V block, V tachycardia
■ More lethal in overdose
⚪ MAOI = don’t give opioids concurrently (drug interac on)
⚪ Mood-stabilizing drugs – Lithium Carbonate
■ Helpful w/ euphoric mania, bipolar disorder
■ Lithium toxicity serum levels close to therapeu c levels
- An convulsants, an -psycho c, combo
- ELECTROCONVULSVE THERAPY – used for pts w/ high suicide risk
- Other signs of depression in older adults:
⚪ Disturbed percep on – confusion, memory loss, delusion, hallucina ons
⚪ Disturbed mood – sad, panic, anxiety, etc
⚪ Behavioral changes – preoccupa on w/ health, death/suicide thoughts, slow response, etc
⚪ Physical findings – cons pa on, tachycardia, fa gue, weight changes
⚪ Complaints – can’t sleep, joint/back pains, neglec ng looks/hygiene, feeling worthless due to age
- Dental Management
⚪ Limit 2 cartridges of epi → may cause severe hypertension w/ an -depressants
⚪ Avoid/reduce seda ve dosages to avoid CNS over-depression

27. SCHIZOPHRENIA
- E ology: triggered by events in gene cally predisposed person (ex. drugs, illness, stress, infec on)
- Clinical Manifesta ons – diagnosis if pa ent has ≥ 2 of the following for 1 month:
⚪ (+) symptoms: hallucina ons, delusions, disorganized/catatonic behavior, disorganized speech OR
⚪ (-) symptoms: affec ve fla ening (restric ve emo ons), alogia (reduced speech), avoli on (mo va on loss)
- 4 types: disorganized, catatonic, paranoid, undifferen ated
- Medical Management
⚪ Tricyclic an -depressants
⚪ An -psycho c (neurolep c) drugs
■ Tardrive dyskinesia – most common extra-pyramidal effect associated w/ long term (yrs +) an -psycho c
meds
 ⦁ Signs/symptoms: involuntary movement of lips, tongue, mouth, jaw, trunk, extremi es
⦁ Elderly = high risk for tardrive dyskinesia
■ Flycatcher tongue = dar ng of tongue in/out
■ Bon-Bon sign = pushing of tongue against cheek
- Sympathomime c (ex. epi) can cause hypotension when given w/ an -psycho cs

28. MULTIPLE SCLEROSIS

- MS is autoimmune → immune system a acks CNS, leading to demyelina on
⚪ Mostly women > men, young onset
- Clinical Manifesta ons: paranesthesia of face may precede other symptoms
⚪ MS diagnosis in 2-4% of pts w/ trigeminal neuralgia
- Random a ack → tx w/ cor costeroids

29. CEREBROVASCULAR ACCIDENT (CVA) or STROKE “BRAIN ATTACK”

- Strokes = blood flow to brain stops either due to ischemic stroke (blood clot blocks blood vessel in the brain) or hemorrhagic
stroke (blood vessel bleeds into the brain)
- Stroke risk = x10 greater in pt w/ previous stroke
- Post Stroke Assessment
Le Brain Involvement (LCVA) Right Brain Involvement (RCVA)
Hemiplegia of R side may include face & jaw Paralyzed L side of body

Slow behavior but intact intellectual processing
Use demos rather than language for instruc ons
↓ auditory memory
LEFT = Language problems
Behavior = impulsive & overconfident
Pt learns through verbal instruc on but pt
should demonstrate understanding
Memory deficits
RIGHT = ENVIRONMENTAL PROBLEMS

- Tx 1 month a er stroke
- Coumadin (tx ok if INR < 3.5)

30. SEIZURE DISORDERS

- Individuals are considered “free of seizures” a er 2 medica ons free years + 2 seizures free years
- Precipita ng Events (COMPARE)
Non-epilep c seizures Epilep c Seizures
Medical orneurological illness Anxiety Loud sounds
Stress/fa gue Bright flickering lights Non-compliance w/ seizure meds
Sleep depriva on Certain smells Drug/drug interac on
Fever Fa gue Menstrual cycle
OH/drug withdrawals Fun drugs Unknown
Syncope Concurrent illness
Infec ous disease
Psychological stress

- Grand Mal (Major Motor): Aura (smell, visual, irritability) → “Epilep c cry” → loss of consciousness
Ictus (~90’’) Post Ictus
Tonic Phase Clonic Phase
Muscle rigidity Uncoordinated bea ng movement of limbs Muscles relax
Pupil dilate & head Consciousness returns
Eyes rolling up or sideways Jaw closing Confusion, mental dulling
Loss of consciousness Head rocking Stupor
No breathing Urinary incon nence Headache

- Pe t Mal (Minor Motor) – Absence Seizures

⚪ Between 5-15 yrs old
 ⚪ No convulsions or fall/collapse/jerking
⚪ Staring w/ flu ering eyelids, some mes twitching facial muscles
⚪ Unaware of surroundings (2-3 sec, rarely 10-30 sec)
⚪ Abrupt stopping of ac vity, no a ereffects, unaware of seizures
- Psychomotor (Temporal Lobe)
⚪ Repe ve stereotypic movements (pull at clothes, lip smacking, etc)
⚪ Emo onal excitement/aura = 1-2 min → confusion → full recovery
⚪ Occasionally followed by generalized seizure
- Jacksonian (Focal) Seizures (Frontal lobe)
⚪ Jerking movement, starts in 1 part & spreads to other parts
⚪ Consciousness maintained (no confusion)
- Status Epilep cus
⚪ Generalized seizure > 15 min or reoccurring seizures w/out regaining consciousness
⚪ Hospitalize if > 5 min → midazolam 0.2 mg/kg IM or Valium 10-20 mg IV
- Medical Management: Vegas Nerve S mulator, surgery, protec ve appliances
MEDICATIONS SIDE EFFECTS
PHENYTOIN (DILANTIN) Gingival hyperplasia
CARBAMAZEPINE (TEGRETOL) Stevens-Johnson Syndrome (flu, rash)
VALPROIC ACID Bleeding & petechiae, ↓ platelet aggrega on

31. AUTISM SPECTRUM DISORDER

- Pervasive Developmental Disorder (PDDs)
⚪ 10-20 cases/10,000 births = classical au sm | 30-50/10,000 = full au sm spectrum
⚪ Live normal lifespan
⚪ Fas ng growing developmental disability
⚪ 4x more common in boys > girls
- Common findings:
⚪ Communica on pa erns
⚪ Lack of interest in peer rela onships
⚪ Make li le-no eye contact
- Defining syndromes:
⚪ Obsessive/compulsive disorder
⚪ Bipolar disorder
⚪ Depression
⚪ Anxiety disorder
⚪ A en on-deficit (ADHD)
⚪ NOT EARLY ALEZHEIMERS
- Asperger Syndrome: Difficulty understanding other’s feelings & normal IQ

32. CEREBRAL PALSY (CP)

- Non-progressive disorder caused by brain damage
- Common clinical manifesta ons: postural/balance difficul es, normal life expectancy possible but some mes early death due to
respiratory involvement, intellectually disabled, ocular defects, seizures disorder, speech defects
- Classifica ons of Cerebral Palsy
Spas c CP
52-70% of all CPs Swallowing impairment/drooling
May not have protec ve extensions Difficulty w/ head control & bending into sit posi on
Hyperirritability of muscles Spas c tongue thrust
Speech impairment Primi ve reflexes
Arms flexed/legs internally rotated Postural difficulty
Atetoid/Diskine c Type CP
25-30% of CPs Con nuous mouth breathers, tongue protrusion
Grimacing Excessive head movements
All 3 extremi es involved Difficulty uprigh ng/balancing
 Drooling, neck & face involved Uncontrollable writhing movement, primi ve reflexes
Speech defects May lack protec ve extensions
Voluntary movements are flailing
Ataxic CP
5-10% of CPS Walk w/ unsteady gait, hard to mo ons w/ precise
Affects balance & coordina on coordina on

33. DOWN SYNDROME (Trisomy 21)

- 40 characteris cs for Down syndrome = no one has all
- Common features:
⚪ Up/outward slant of eyes w/ narrow, short eye slits
⚪ Fold of skin over inner side of eye (epicanthal fold)
⚪ Small, white patches on edge of iris
⚪ Flat facial appearance
⚪ Smaller head size
⚪ Frontanels larger than normal
⚪ Smaller, lower set ears
⚪ Small maxilla → tongue protrusion
⚪ Short neck, arm & legs
⚪ Broad & flat hands/feet, short fingers/toes
⚪ Hypotonia, loose-jointedness (hyperflexibility)
⚪ Weaker reflex
- Clinical Manifesta ons
⚪ DS tend to be warm & well behaved but some can be uncoopera ve
⚪ Cardiac disorders
■ Mitral valve prolapses (>50% adults)
■ Congenital heart defects (40-50% cases) → patent ductus arteriosus, Tetralogy of Fallout, septal defects
⚪ 20x ↑ risk of acute lymphoid leukemia in DS popula on
⚪ Tend to develop Alzheimer’s Disease (AD) > 40 years old
⚪ x7 ↑ risk of having HBV
- Oral Manifesta ons
⚪ Periodontal disease – poor OH, malocclusion, conical-shaped teeth, compromised immune system
⚪ Orofacial features: midfacial underdevelopment, strong gag reflex (anxiety, tongue posi on), high & narrow palate,
hypotonic (drooped mouth, protruded lower lip)
- Set on short recalls → 3-4 months
- Prescribe fluoride gel or toothpaste + chlorohexidine 0.12% rinse if pa ent can control swallowing reflex

34. INTELLECTUAL DISABILITY

- Know dental management & tx modifica ons

35. VISUAL IMPAIRMENT

- Cataract (gradually blurry vision) = leading cause of blindness world wide
⚪ Tx: cataract removal surgery + lens implanta on
■ Tx w/ α-1 antagonist (tamsulosin) or risperidone ↑ risk of complica ons
- Glaucoma = unstable/sustained ↑ in intraocular P → causes damage to structure or impairment of func on
- Diabe c Re nopathy
⚪ In US, 40% of diabe cs have re nopathy
■ 20% Type II have re nopathy @ diagnosis
⚪ Leading cause of blindness in adults 20-65 yrs old
⚪ Early Re nopathy – poor glucose control causes capillary fragility → micro aneurysms
■ Block blood supply
⚪ Later Stage Re nopathy – fragile capillary growth → hemorrhage
⚪ Tx: diabe c glycemic + HTN control is most important
 36. HEARING IMPAIRMENT
- Ototoxic drugs involve aminoglycosides an bio cs, loop diure cs, an -neoplas c agents, salicylates
Pre/Peri Natal Causes Post Natal Causes
Premature Infec ous disease: meningi s, measles, mumps, chronic ear
Anoxia during birth infec on
Infec on of the mother: rubella, syphilis Ototoxic drugs at any age
Ototoxic drugs Head/brain trauma or ear injury
Jaundice of newborns Aging
Smoking
Excessive noises

KNOW HOW TO WRITE A MED CONSULT

KNOW HOW TO WRITE A PRESCRIPTION

KNOW WHAT ARE COMMON QUESTIONS TO ASK FOR CERTAIN CONDITIONS