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Human Diseases (Cardiovascular Disease (Heart Failure (Left Ventricular…
Human Diseases
Cardiovascular Disease
IHD
Angina Pectoris
Increased O2 demand by heart due to obstruction results in substernal chest pain
STABLE = chronic stenosing atherosclerosis
UNSTABLE = progressively increasing duration and frequency (predictor of MI)
Management
Drug Therapy
Rest (i.e reduce stress/anxiety)
Nitrates
= Ca+ influx ∴ relax smooth m./ Dilation
ex. Glyceral Trinitrate(GTN), Nitrous Oxide
MI
Obstruction leads Infarction/ischemia which can develop into necrosis
Tx = MONAH
Morphine
Oxygen
Nitrates
Aspirin
Heparin
Complications from MI
Arrythmia, shock, heart failure, pericarditis, hypertension, DVT/PE, Cardiac rupture, Cardiac Arrest
Hypertension
SBP >135mmHg & DBP >85 mmHg
Stages 1-3 (increasing pressure)
Essential Hypertension
no attributable cause, assoc. w/ ageing
QoL dramatically improved if treated
Secondary Hypertension
Renal or Hormonal related
Need to tx underlying cause to resolve HT
Management
Drug Therapy
Life style changes
Diuretics
= cause Na+ loss ∴ ECF/BV reduced
acts on renal tubules
ex. Thiazides, Loop Diuretics, Mannitol
Beta blockers
= B1-agonist ∴ HR reduced + vasodilation
ex. metoprolol, atenolol, celiprolol
nb. can cause fatigue, bradycardia, postural HT, cold hands
ACE inhibitors
= prevents ANG I to ANG II conversion ∴ reduces BV & Aldosterone levels
ex. Cilazapril, enalapril
nb. dangerous w/ pts. that have renal impairment
Calcium Channel Blocker
= reduces intracellular Ca+2 levels ∴ vasodilates smooth m.
ex. Verapamil, Nifedipine, Diltiazem
Heart Failure
Right Ventricular Failure
Odema, pitting of lower limbs, ascites
Left Ventricular Failure
pulmonary odema
external SOB & Orthopnoea
Drug Therapy - Diuretics, ACE Inhibitors, Nitrates, Digoxin
Dental Considerations
Hypertensive Patients
:check: hx, medications, systems review (check BP), :check: chairside management, avoid vasopressin , Post-op bleeding considerations
Angina Patients
GTN at hand, reduce pt. stress/anxiety, NO adjuncts, avoid intravascular injections, aspirin
Heart Failure Patients
Cannot lie flat, often cough, postural HT, Diuretics
Coronary Angioplasty Patients
(anticoagulants!?) consider prophylaxis if tx needed within 6months of placement of stent
Valve pathologies Patients
Rheumatic valve disease, prosthetic valve, mitral regurgitation
Antiobiotic prophylaxis protocol
Risk Factors:
Modifiable - HT, DM, Hypercholesterolemia, Obesity, Smoking
Non-Modifiable - Family hx, EOHD, Perivascular procedures, Male, Age
Amoxycillin(2g) Prophylaxis
• Orally 1 hour before the procedure
• IV just before the procedure
• IM 30 minutes before the procedure
• If allergic to penicillin, use Cindamycin (600mg) (as 5-10% chance of cross-reactivity with cephalosporins)
Anesthesia & Sedation
Management of patient
Patient Prep
Empty Stomach = NO FOOD (6hrs before) NO DRINK (2hrs before)
Medical Prep
ECG, chest-xrays, blood examination
allow special req. for diabetics, pts. on anticoagulants, cortisol, MOAs
Diabetics =
Keep BGL ~ 4-6 mmol/L, IV insulin/glucose administered as needed,
Preoperative insulin stabilization, preferably no more than 1 meal missed.
Assess diabetic control – HbA1c
Risks
Cardiac arrest
Anesthesia and surgery confer a physiologic stress test to the patient that increases O2 demand
Related to airway management and medications
Allergic reactions to medications
Causing anaphylaxis
May have cardiac, cutaneous, and respiratory symptoms
Collapse of lung
Bronchospasm
Triggered by airway instrumentation and inhalation anesthetics
May result in hypoxia, hypotension, and death
Aspiration
At intubation and extubation
Aspiration of gastric contents into the airway is the most common cause of airway-related death during anesthesia
Malignant hyperthermia
disordered regulation of calcium within skeletal muscle leading to a hypermetabolic state (hereditary)
triggered by muscle relaxants
may result in tachycardia or hyperthermia
Cerebral Hypoxia
Stroke
Death
Minor Complications
Drowsiness, headache, vision problems, mood/mental issues, nausea, vomiting, sore throat, nightmares
Procedure Overview
Premedication
relax and calming patient & midazolam, atropine
Induction
I.V agent (propofol) or inhalation agent (sevoflurane)
Intubation
oral, nasal, laryngeal mask/intubation
Maintenance
mixture of inhalation agent and O2 (eg. Isoflurane w/ O2)
Recovery
discontinuation, manage airways, post-op pain control, antiemetic drugs, O2 + monitoring
Renal Disease
- functions of kidneys:
regulation of fluids, electrolytes, waste products, blood pressure, acid-base balance, glucose/RBC synthesis
ARF
acute deterioration of renal function over hours/days
A marked increase in plasma urea/creatinine
causes: cardiac failure, hypotension, acute tubular necrosis (ATN), vasculitis, pyelonephritis
CRF
progressive loss of function until diminished
(i) Nephrotic Syndrome = proteinuria, peripheral odema
(ii) Nephritic Syndrome = haematouria, fluid retention, hypertension
(iii) Glomerular nephrtiis = (immune-complexes)type III hypersensitivity
Dental Considerations
need systems review (Hx)
secondary hypotension
assess pateints health
perioperative antibiotics
impaired immunity levels
infection control and prevention
Respiratory Disease
COPD
Emphysema
Characterized by permanent enlargement of the acinar, accompanied by destruction of their walls without significant fibrosis
There are four major subtypes including- centriacinar (smoking-related), panacinar (seen in α 1 -anti-trypsin deficiency)
Chronic Bronchitis
Defined (clinically) by the presence of a persistent productive cough present for at least 3 consecutive months in at least 2 consecutive years
Features of chronic bronchitis are hypersecretion of mucus, beginning in the larger airways.
Bronchial Asthma
Chronic inflammation and remodeling of the bronchi. Characterizied by cough, wheezing, dysponea
early onset (atopic IgE mediated)
late onset (non-atopic)
Dental Considerations
:check: medical hx of COPD, asthma or other resp. disease with consideration of associated heart disease, and consultation with patient’s GP to determine control.
Low risk
: dyspnoea with effort, normal blood gas levels: only minor complications during dental Tx.
Moderate risk
: dyspnoea with effort, long-term bronchodilator/corticosteroid medication, PaO2 lowered. Need to consult GP to determine control before dental Tx.
High risk
: highly
symptomatic
and may be refractory to medication. Need to consult GP before dental Tx. Consider treating in special care facility (e.g. hospital).
Preoperative preparation
: smoking cessation for 1 week before the appointment, and the patient should be clear of any respiratory infection. COPD should be medically stable (no breathing issues) before dental Tx, early and focused appointments
:<3: Best to treat COPD patient in semisupine position to prevent orthopnoea. Cotton-roll isolation (not rubber dam) for those that struggle with more apparent breathing difficulty.
Local anaesthetic not contraindicated
Sedatives and G.As should only be used when absolutely necessary, as these impair the respiratory nuclei in the brainstem, causing respiratory depression.
Theophylline can interact with a number of drugs: adrenaline, erythromycin, clindamycin, azithromycin, clarithromycin, ciprofloxacin – resulting in high levels of theophylline and adverse effects
Ipratropium (long-acting muscarinic antagonist) can cause dry mouth
Steroid Inhalers can cause oro-pharyngeal thrush
Endocrinology
Diabetes
Types
Type 1 - Insulin DEFICIENT
Type 2 - Insulin RESISTANCE
Type 3 - Gestational Hyperglycemia
Complications
Acute/Chronic Complications
Disorder metabolism (i.e dyslpidemia, DKA, lactic acidosis)
Infection Suseptibility
Micro/macroangiopathy
Immune defects (i.e diabetic foot, nephropathy, retinopathy)
Oral Complications
Periodontal disease (can affect glycemic control and predispose severe PD disease)
Impaired wound healing (i.e dry socket)
Xerostomia (dehydration)
Oral candidosis or Sialadenitis (infection susceptibility)
Dental Considerations
:check: Hx and Ex - DM review
including age onset, diaognosis, management(i.e HbA1c), hospitalisations, medications (i.e drug regime, doszage, frequency)
:check: Tx in appointments:
Physical Care
padding to prevent ulcers
Antibiotic Cover (Avoid infections)
Unconscious diabetic pt. GLUCOSE FIRST (not insulin)
Hypoglycemia
Morning appointments
Make sure meal + insulin
Tx should not interfere with eating (within 2hrs of meal)
Perioral paresthesia (common) – sign of impending hypoglycemia
Consider administering oral glucose if meal skipped/ BGL <5mmol/L
Hypoglycemic/hyperglycemic or Coma (Unconsious) event = GLUCOSE FIRST (not insulin)
Treatment
Insulin Regime
Variable, Long-acting & Short-acting mixture
Oral Hypoglycemics
Sulfonylureas – glimepiride, glipizide, glyburide
Biguanides – metformin
Thiazolidinediones (Tzd) – pioglitazone, Actos generic
Lifestyle Changes
Diet, exercise, blood glucose monitoring
Adrenal Gland
Adrenocortical disease
Hyperfunction:
Cushing Syndrome - buffalo hump, moon facies, poor wound healing, HT
Conn's Syndrome (adrenal adenoma)
Hypofunction:
Addison's Disease (primary or secondary)
Corticosteriod Therapy
Therapy in Dentistry
replacement
anti-inflammatory/immunosuppressant
Bell's palsy
Post-op pain & odema control
Adverse Effects & Dental Patient
HPA Suppression
systemic use exceeds daily secretion = can reduce capacity to respond to increase cortisol demands (adrenal insufficiency)
this can lead "Adrenal Crisis" in some events
Diabetes mellitus (impaired glucose tolerance)
Hypertension effects
Poor wound healing (+/- DM)
Susceptibility to infections
Oral Candidosis (particular in patients who use inhalers)
HSV/VSV
Management of LT-Steroid Usage
NEVER abruptly stop (will shut down adrenal gl.- SHOCK)
Rule of 2's
2 weeks therapy or 20mg hydrocortisone therapy
within past two years (AT RISK of HPA suppression)
preoperative must have sufficient levels to cope w/ stress
Medical Imaging
Intraoral
Plain Radiograph
Adv. readily avaliable, less expensive, portable, instant, painless
Disadv. radioation exposure, poor diagn. accuracy, superimpos, poor soft tissue
Invasive Radiography (contrast media)
Sialogram (glands)
Angiography (vasc.)
Extraoral
OPG (lower pano)
good for evaluation of trauma, large lesions, retained teeth, TMJ issues
Cone Beam CT
adv. less expensive, less radiation, smaller machine, 3D reconstruction
disadv. Innacurate bone density, s.t. unreliable, small surface area scanned
MRI
adv. non-ionising, painfree, excellent s.t. contrast, all three planes
disadv. long scan time, metal interference, high specifics
Surgery and Trauma
Principals of Surgery
Surgery is irreversible
nb: necessity, biological cost, pros/cons)
At first do no harm
Thorough examination, planning, perio, post-op management plan
Informed Consent
Primary Survey (ABCDEs)
Wound management
Hx:
Mechanism of injury (how, & timing)
Ex - site, minor/severity, supf./deep, soft/hard tissue, dirty/clean
Investigation/Diagnosis - Bloods, Imaging ect.
Tx:
(i) Visual examination
(ii) Washout and debridement
(iii) Surgical process
Principals:
Replace to normal positions - i.e like to like (epi-epi/endo-endo)
Treat primary defect (losses must replace in kind)
Gentle handling of tissues - meticulous suturing & maximise cosmetics (w/out functional compromise)
Healing
Tissue Healing
Regeneration
- Liable & Stable Cells
(i) Neutrophils infiltrate (ii) Reepithelisation
(iii) Macrophage infiltrate (iv) granulation tissue
(v) collagen and c.t
Repair
- Permanent cells
(i) Demolition
(ii) angiogenesis (iii) fibroblast migration/prolif
(iv) deposition of ECM (v) maturation and scar redmodelling
Socket Healing
Haematoma in socket
Demolition of hematoma (MAC) and necrotic bone (osteoclasts)
Regeneration of epithelial surface
Clot replaced by granulation tissue (1-3 weeks)
Production of woven bone
Remodelling
Bone Healing
(i) Inflammation Phase - hematoma, necrosis, acute inflammation
(ii) Reparative phase - callus formed and organized, clearance of clot
(iii) Remodelling phase - reorganization of bone and OB/OC activity
Summary List of Lectures:
Diagnosis and investigations :check:
Medical Imaging :check:
Principles of surgery :check:
HIV & AIDS
Immune disorders :check:
Anaemia
Acute & Chronic infections
Wound management :check:
Renal :check:
Anaesthesia :check:
Respiratory :check:
Endocrine I-IV :check:
ENT surgery
Burns and fluid
CVD :check:
Liver and Hepatitis
Oncology
Orthopaedics
Vascular diseases and neurosurgery