Please enable JavaScript.
Coggle requires JavaScript to display documents.
CH lecture mx of medically complex pt, Drugs and therapeutics, Medically…
CH lecture mx of medically complex pt
concept: formulating tx plan
In healthy pt
C/O
tx plan and execution
but what abt in a
medically complex pt
?
concept 1: pt assessment: impact of med conditions and associated therapy on dental tx
concept 2: risk assessment (pre-)
adverse events at risk
carry out necessary consults, investigations, precautions
how to modify tx plan? precautions?
concept 2 contd: risk re-assessment during procedure
...
...
allergy
types of hypersensitivity
1 and 4 most common in dentistry
Type I: IgE-mediated/anaphylactic
Type IV: T lymphocyte mediated, often w prominent skin findings
eg. EM, contact dermatitis, GVHD etc. HLA associations
prevention & tx
acute
emergency tx
chronic
desensitization (more common for kids)
...
immu...
common culprits in dent
LA
more common ester > amide
IDONGETS
"if true allergy --> ..."
true allergies are rare! for these pt, need GA cos cannot LA
PCN
sensitization...
skin testing is q accuracy
cross-rxn w cephalosporins (~5%, but for type I sensitivity say to amox u rlly dw give ceph)
basically vancomycin is like the best for now, but cos not a lot of R&D in ABs, this one hasn't rly developed in the past 30 years --> rlly don't wna anyohow give --> cos develop resistance
Analgesics
ASA: caution w asthmatic pt
NSAIDS
codeine
Latex
type I and IV (rare) hypersensitivity reported
Dent materials
type I, III, IV hypersensitivity reportted
Rheumatologic diseases
RA
OA vs RA
etc...
most relevant for TMJ manifestation
LE
note oral manifestations
Sjogren's syndrome
hyposalivation --> rampant caries
got some slide on allergy plus rheum tgt
HIV/AIDS
molecular techniques dont need
AIDS is v advanced, end-stage
these pts are very sick
usually non-compliant w medications or co-morbidities
slides on dental tx using the concepts
concept 1: ... CD4, CD8 and WBC count to determine immune status. HIV usually WBC count a bit depressed, but can be. ...
concept 2: risk assessment
cancer
types of cancers, broadly
hematologic malignancies
solid organ malignancies
tx
RT for H&N cancers
slide w overview
Drugs and therapeutics
General principles for prescription
Common drugs in general dental practice
for each, know
DDI
contraindications (absolute and relative)
dosing
analgesics
Non-opioids
Paracetamol
NSAIDs
Opoids
Should not be prescribed as the first-line tx for acute & chronic pain
Combination
antimicrobials
corticosteroids
sedatives
local anaesthetics
prescribing in pregnancy/lactation
oral side effects of meds
Medically complex patient
Thinking frame for mx
(intro lect)
Follow this flow!
Medical hx, exam
Risk assessment
Classification
Consultation with medical doctor/specialist
Tx modification
Pre
Intra
Post-op
Purpose? (slide 7)
assess pt ability to tolerate dental care (outpt, hospital-based setting)
minimise risk of adverse events
identify pts requiring further med evaluation pr stabilisation, may need to defer tx
identify pts requiring pretx modifications, therapies
Looking at past med hx
ask abt past illnesses (incld hospitalisations/surgical hx)
then, probe further! ask specific relevant conditions (eg. bleeding problems, pregancy, epilepsy, respiratory, cardiac, neurological conditions, oncologic diseases
tx (past, current, intended/future)
med hx (past, current, future)
Review of systems
enquiring abt symptoms associated w specific organ structures
What is it done for?
attempts to detect unrevealed symptoms/undx disease
monitor changes in medical conditions
establish severity/stability of medical condition and how it affects normal daily activities (fx capacity)
Systems (slides 17-18)
General conditions to ask about
asthma
bleeding tendency
cancer
chemotherapy
coronary artery disease
diabetes
epilepsy
G6PD deficiency
heart defects
hepatitis
HIV
hypertension
implant medical device
kidney disease
liver disease
osteoporosis
pregnancy
psychiatric disorder
radiotherapy
stroke
I find that pt has medical condition XYZ. What should I ask/think abt next?
assess degree of control & severity of med condition (complications, target organ damage)
tx & meds
types
compliance
recent chanegs
regular & supervised care w physician?
recent tests eg. FBC, blood glucose, INR, ECG
symptoms associated w condition -- are they present or absent?
how are the symptoms controlled? is there response to usual medications?
hospitalisations? recent acute/adverse events
recent increase in severity (exacerbations)?
any procedures done recently?
other things to think abt: nature (type), severity, symptoms, meds, blood investigations, timing of events (adverse events, procedures performed), fx capacity, associated disorders, complications, severity
What are these medical complexities?
Let's look at systems & conditions in detail
CVD (AR lect 20/5/24)
only followed from slide 55
Cardiac arrhythmias
definition (slide 54)
CEID (pacemakers/ICD)
Angina & myocardial infarction
cardiovascular disease
valvular disease & co-morbid conditions
prosthetic heart valves
IE
risk
s/s
prophylaxis
indications
common ones and dosages
Infective endocarditis
What is it?
Guidelines: AB prophy
indications
ABs
AHA 2007, and updated in 2021
Significance?
Etiology?
Heart failure
Hypertension
What is it?
Significance?
Classification (MOH)
In dental setting, watch out for
acute hypertensive crisis!
This is a medical emergency
can lead to stroke, AMI, etc.
Respiratory
(in the dental context, we focus on obstructive airway diseases)
Asthma
COPD
comprises bronchitis and emphysema
OSA
neurological conditions
fits & epilepsy
Stroke
What is it?
General info
General features
Oral features
Otehr mx issures: possibilities of another stroke, compliance and consent issues, comorbidities and other issues
linking this to dentistry in the clinic
pre-dental evaluation!
dental aims for neuro pt, a bit diff from regular pt
slide 39: defer elective dental procedures etc.
slide 40: as a clinician, u have a part to play in monitoring complianece & control of condition
slide 41: mx of aphasia
tx planning
pre, during and post dent considerations. for these pts, communication is key!!!!
Dementia
types
Alzheimer's type dementia (ATD)
vascular cognitive disorders
...
problems
etc. look at list slide 57
multimorbidity
OH deterioration
dental mx
predental evaluation
tx planning
during tx
consider the stage early, intermediate, severe, late
Parkinson's disease
oral features
restoration of OH best completed early in the disease process
dental considerations....
others: geriatric dental pt, drugs in dentistry, medical emergencies in dental practice
geriatric pt assessment, slide 6
MOH study: common drug allergies are NSAIDs, ibuprofen, augmentin
metronidazole and aspirin, nsaids --> increased risk of bleeding!
