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Tables
Grades Autotransplant : no problem Isotransplant = donor and Allotransplant = same species Xenotransplants = from
immunological/rechazo (teeth, receptor same e.g. twins another species
organs)
Neoplasias Types - associated immunosuppression Factors After changing immunosuppressant drugs e.g.
- squamous cell carinoma - Immunosuppression therapy Kaposi sarcoma went down when doctor
- linfoproliferativos e.g. linfomas - Age changed medicine to Sirolimus.
- Kaposi sarcom - Habits and predispositions
- Episodes of rejection
4. Cardiovascular
Rheumatic Antibiotic prophylaxis = except in placement of prosthesis and adjusting orthodontics.
cardiopathy
Antibiotic prophylaxis 2g amoxicillin/cephalexin/ampicillin 30 - 1 h before 600mg clindamycin 500mg azithro/clarithro
Innocent/fuctional increase in the blood flow. – no actual problem, the sound when too much blood going through
murmur • Children of 5 to 7 years
• Pregnant
• Not necessary to give antibiotic profylaxis – but if there is any doubt, we should
Cardiac insufficiency • Beta blockers • Aldosterone blockers
• Diuretics • Calcium channel blockers
• Angiotensin 2 blockers • Digoxin – narrow therapeutic window
Management CI - Check BP
- Position of the patient – can’t lie completely flat as can’t breath properly
Can’t lay them flat - Short appointments
- No rubber damn- 1 or 2 yes but 3 no.
Decompensation of • Cold skin arriving little blood to the skin • Tachycardia – compensation for lack of force
the cardiac • Arterial hypotension - compensation • Tachypnoea –
insufficiency
Grades – cardiac I asymptomatic – treated as II - moderate activity – fatigued III – smooth activity. IV – resting –
insufficiency normal healthy patients – max under these, running/exercise. – we don’t treat these go to
2 carpools normal healthy patients – max 2 URG – during normal activity hospital
carpools
Interactions Clavulanic acid + digoxin à Increases the action of the anticoagulants with the risk of haemorrhage by the alteration of the floral
intestine that inhibits the formation of vitamin k.
Instead we increase the amount of amoxicillin rather than adding clavulanic acid.
Cardiac ischemic Mortality - Age - High level of - Being a man – - Arterial - Tobacco
cardiomyopathy - Diabetes lipids serology. women have hypertension
Coronary hormonal
Risks involved: arteriosclerosis protection
Management of - Short Anesthesia with Avoid retraction Avoid anti- Stick to same - Control stress –
appointment vasoconstrictor cord with adrenalin cholinergic as Anesthesia – due to BDZs –
stable anginal morning! soaked produce tachcardia, preservatives, same
and old stroke 2 carpoules - atropine brand - diazepam 2-5mg,
(+6 months) - Semisupine Doses - Oximetazolina - esocopolamine. - Anesthesia
positon - Tetrahidroxolina without - lorazepam 1mg,
>6 m max of adrenalin inhibits the vasoconstrictor control pain
- Take BP and 0.036 mg muscarinic actions of or with
acetylcholine
heart rate vasoconstrictor
Management of Only urgent cases • BDZs always Angina unstable – Anaesthesia Cafinitrina = has caffeine and nitroglycerine
are treated by us • 10mg nitro-glycerine – this drug is a
unstable angina – we wait for after oxazempam sublingual before
without spasmolytic – makes blood vessels expand
or stroke in less 6 months to do or treatment – brand vasoconstrictor and open more all over the body, avoiding
than 6 months the rest of the • 5mg diazepam name Cafinitrina always. compressive pain.
treatments, only the night before with caffeine
<6 m very urgent • The same 1 hour Caffeine will increase the power of
treatments to do before consult contraction of the heart, will avoid
now. problems of lack of supply of blood to the
heart.
Stent ¨ Never stop treatment of platelet anti-aggregant like Adiro 100mg (300mg or more we speak to cardiologist to reduce the dosage
temporarily only on the days of specific surgery).
¨ Delay non-urgent invasive procedures with risk of bleeding.
Types of stents Metallic stent : 4-6 weeks after angioplasty. Farmacoactive stent: 6-12 months. – coated in medicine.
Farmac = no prophy
Sintrom
2 days before stop sintrom Start LMWH ( 20mg of enoxaparina)
1 day before No sintrom Continue LMWH
Day of the Use tranexamic acid locally, restart sintrom that night Continue LMWH
appointment
2 days after Sintrom continue LMWH continue depending on case – some high risk patients 2-3
days after doctor might say continue only with sintrom
Sintrom after all Before patient with risk of thromboembolism is high, the profilaxis with lmwh it will be mainitained for 3 days after the appointment.
Pacemaker
pacemaker First 6 months of placement – antibiotic prophylaxis
pacemaker - Generator sets - MRI machines
- Welding equipment - Radiation therapy machines for cancer treatment
- Some device used by dentist: ultrasound (curate), electric - Heavy equipment or motors with powerful magnets.
scalpel (tranexamic acid instead as used to stop bleeding/ or
applying pressure) and apex locator (do x-rays old school)
5. Dental management of pregnant women
1st trimester • 50% spontaneous abortions (due to egg alterations, maternal causes, external aggressions)
• Possible teratogenic effects
• (before 2 weeks of gestation = death of the egg,
• between the 2nd week and 2nd month = important organic defects End of the first trimester = small organic defects).
• 1st trimester reduced arterial hypertension (bradycardia)
2nd trimester • Growth of foetal structures and maturation of organs.
Best time to treat • No teratogenic but toxic effects
• Best trimester for treatments
3rd trimester • Toxic effect
• Maximum size
• Possibility of provoking/advancing labour.
• In third trimester avoid lying the women down, due to hypotensive dorsal decubitus syndrome.
Hypotensive dorsal by compression of the uterus on the vena cava inferior taking down the blood pressure, bradycardia, sweating, nausea, loss of
decubitus syndrome conscience.
Special precaution • Change of habits, change of hours periods of anorexia, and excess apetitie
• Sialorrea
digestive • Nausea and voming common
• By hormones increased oestrogen HCG, progesterone, 1st week
• Immune changes
• Changes in habits; pregnant women eat more - increased carbohydrate intake, increase of salivation, nausea and vomits
respiratory • Increased breathing – tachypnoea
• Dyspnoea ( > in the last week> lying down)
Hormonal gingival and perio
Gestational choasma during second half of pregnancy- brownish colour in eyes and maxilla due to melanocytes increasing ACTH.
Gingivitis • 50-100%
• Starts in 2nd month until 8th month
• Clinically of colour red, increased volume, smooth surface which is bright, random bleeding/
• Papilla hipertroficia and seudobolsas
Immunological • Reduction of T lymphocytes - CD3 and CD4
• Reduction of the response of the cells in the gum> inflammation.
Epulis Gravidico • Clinic = Thickening of the ginigiva (V), in papilla, intense red for being rich in vasos. (increase hemorrhagia) base pedicle o sésil.
• Asymptomatic.
• Gingivs and placa.
• Appear 2nd trimester, decreases in size after pregnancy (no> de 2cm)
• History Similar to pyogenic granuloma, changes of inflammation and hyperplasia. – will cut it around the healthy tissue as
impossible remove with scalpel
Varnish and Avoid fluor until 4th month 1-1.5mg – caries cuello
mouthwash
Breast feeding All of the pass into the milk more or less half amoxicillin and paracetamol ok
Pharma Pharmacological low weight molecular they pass to the milk proportion 2-3%/ in blood.
6. Epileptic patients
Oral manifestation • Xerostomia
• Caries
• Cicatrices in the tongue
• Severe attrition
• Limitation of the apertura of the mouth
• Dry lips
Benzodiazepine • Lorazepam 1 mg the night before and one hour before the intervention
• Diazepam...5mg
Nitrous oxide Avoid increased toxicity in anti-epileptics
Times early in the morning or during the workday, without making you wait excessively + short
Protocol Management in the clinic of the epileptic patient
1. Eliminate triggers factor (light, noises, anxiety)
2. Appointment after taking meds
3. No NSAIDs, increased risk of haemorrhage, metabolism hepatic. NO administering erythromycin or propoxifeno to patients that
take carbamazepine.
4. Put back space edentulous, protesis fixed, metallic posterior and resin in anteriors. Avoid removable dentures. Resin easier to fix
than porcelain.
5. Use mouth openers
Protocol in epileptic - Remove all dental instruments and materials
crisis - Remove removable prosthetic or orthodontic appliances
- Place supine, on the couch or on the floor
- Avoid hitting the head or limbs
- Separate objects with which the patient may be damaged
Specific measures - Place a guedel cannula or rubber wedges in the mouth – we have various sizes, try and insert without putting the fingers in the
mouth
- Place the head to the side
- Aspirate secretions and saliva if possible
- Keep the airway area clear
Therapeutic measures • If the crisis lasts more than 5 minutes
during a seizure • Ensure adequate ventilation - Administer oxygen with mask.
• Administer benzodiazepine:
• Intravenous route: diazepam 10-20 mg in adults 0.1-0.3 mg / kg in children
• Rectal route: diazepam (10-20 mg).
• If epileptic seizures persist after 15 minutes, the patient should be transferred to a Hospital Emergency Department
Action before an • Measures in the postcritical phase of epileptic seizures
epileptic crisis • Monitor respiratory rate
• Assess the degree of wakefulness and orientation
• Administer IV 1 ampoule of 50% glucose
• Administer 100 mg of thiamine IV if alcoholism
• Diazepam effect can be reversed with flumazenil (Anexate)
• Local priests if oral or lingual wound
7. Oncology
Immediate - soft • MUCOSITIS / DERMITIS – inflammation fo the skin and areas recieveing radio.
tissue – first weeks to • Dysgeusia – alteration in perception of tongue, won’t be able to feel flavours in same way.
months • GLOSODINIA
• XEROSTOMY –
Medium term • CAVITIES – due to lack of saliva
• TRISMUS - FIBROSIS –loose their elasticity and tendons will suffer the same fate. Due to alterations in the muscle will result in
the patient having trismus. Problems opening the mouth and feeding properly. Mainly affecting the pterygoid muscle and
masseters
• DYSPHAGIA – problems swallowing
• MUCosa NECROSIS – mucosa will start to suffer erosions and spontaneous ulcers.
Long term • OSTEONECROSIS – tissue which will be effected in long term, sometimes spontaneous.
• ALT. DENTAL
o AGENESIA
o ALT. CORONAL
o ALT. RADICULARS
GUIDELINES FOR Clinical history systemic pathologies, medication, type of therapy patient will receive and how many sessions, and very important
ACTION ON when will the patient receive radiotherapy!!! – as is time crucical as have to have all treatment finished before the patient starts.
Mucositis PAIN:
o ALKALINE SOLUTION (Maalox) + 4 AMPOULES OF A LOCAL ANESTHETIC (2%). o RINSES WITH TWO TABLESPOONS HALF AN HOUR
BEFORE MEALS
o TOPICAL CORTICOIDS, side effects .
Cleaning Cleaning:
o 100ml OFWATER + SALT + BICARBONATE – this avoid the possible over infection of candidiasis.
Cryotherapy 30 minutes to prevent - oral mucositis in patients receiving bolus 5-fluorouracil chemotherapy (II)
Low level laser to prevent oral mucositis in patients receiving HSCT conditioned with high-dose chemotherapy, with or without total body irradiation
therapy (II).
Benzydamine prevent oral mucositis in patients with head and neck cancer receiving moderate dose radiation therapy (up to 50 Gy), without
concomitant chemotherapy (I). A medication used for anti inflammatories and analgesic.
Morphine morphine be used to treat pain due to oral mucositis in patients undergoing HSCT
Transdermal fentanyl treat pain - oral mucositis in patients receiving conventional or high-dose chemotherapy, with or without total body irradiation (III).
2% morphine may be effective to treat pain due to oral mucositis in patients receiving chemoradiation for head and neck cancer (III).
mouthwash
0.5% doxepin mouthwash may be effective to treat pain due to oral mucositis (IV)
XEROSTOMY AND o GLANDULAR DYSFUNCTION IS DEPENDENT DOSE 60-70 grays of radiation, we get this one of the most important side affects of
HYPOSIALIA xerostomia.
o MORE SENSITIVE SERIOUS ACINIS -
o SALIVA DENSA, STICKY, MUCOSA
o ACINOS ATROPHY
o VASCULAR ALTERATIONS
o FIBROSIS
o Tissues are very shiny, massive lack of saliva. The mirror will get completely stuck to mirror.
Xerostomia help o INCREASE LIQUID INTAKE. 2-3 L / day
o SORBITOL BASED CHEWING GUM
o SUBSTITUTES FOR SALIVA. ARTIFICIAL SALIVA
o PILOCARPINA 5mg / 8 hours – the only thing that works, pilocarpine 5mg/8h
o CARBOXIMETILCELULOSA Na (0.5% in aqueous solution)
o LIP BALM – labio protector important to protect lips. Kin hidrat spray.
Osteoradionecrosis Due to....
- DECREASE IN THE NUMBER OF OSTEOCITS
- DECREASE No OF OSTEOBLASTOS
- VASCULAR ALTERATIONS
Exos in patient treated • 3 to 6 weeks BEFORE RT – even better to do exos 6 weeks before.
with radio • 8 months to a year AFTER RT – 8-12 months after before we can do exos again.
• Implants 2 years later
• ANESTHESIA WITHOUT VASOCONSTRICTOR (Post.) - before you can, after radio only without adrenalin due to devascularisation.
• CURETEAR ALVEOLO
• SUTURE – after exos
• RESPECT THE PERIOSTIO – If we break or damage it during exos, we get more complications.
• Don’t need to give antibiotics before exo.
• ATB COVERAGE always post – 1 week 700mg amoxic/8 h
• ANTISEPTIC ROUTINE. CHX daily.
CANDIDA INFECTION
Trismus Physiotherapy and prevention are the best weapons to prevent this pathology. Consistency in exercises will greatly improve your
quality of life.
The patient should continue to check regularly and avoid all types of carcinogens (tobacco, alcohol ...)
How long will we see the patient during radiotherapy, we should see them once a week, we can find a really big change from one
week to the next week. Mandatory to see the patient weekly, take pictures and re-assess the mouthwash.
8. Diabetes
Grades Normal Prediabetes Diabetes
Fasting 70-100mg/dl Fasting 100-125mg/dl >126mg/dl fasting
After 2 hours less than 140mg/dl After 2 hours 140-199mg/dl >200mg/dl after 2 hours
HBA 1 c • NORMAL 4.1-5.5% • PREDIABETES between 5.6% and 6.4% • DIABETES greater than 6.5%
If a patient has both renal insufficiency and diabetes they have to control and adjustment of insulin, so the amount of insulin they need
will be controlled by endocrine. – the worse the renal insufficiency, the less insulin they will have.