Final Exam

Oral cancer

-red, white or mixed red and white lesions -ulcers persistent beyond 14 days (including non-healing denture sores after adjustments) -prolonged hoarseness of voice or a feeling of something in throat -unexplained numbness -ear ache -a lump or thickening that develops in the mouth or head and neck area -look beneath the dentures other signs and symptoms: -a sore that bleeds -a growth, lump or thickening of the skin or lining of your mouth -loose teeth -poorly fitting dentures -tongue pain -jaw pain or stiffness -difficult or painful chewing -difficult or painful swallowing

Prevalence and incidence

-2.7 million are newly infected with HIV annually -an estimated 33.4 million persons globally (2009) -1.1 million persons in the U.S. who were infected and living with HIV infection/AIDS >24% are undiagnosed and unaware of their infection -42% are HIV positive but have not yet progressed to AIDS -34% have AIDS -the average dental practice encounters at least 2 patients infected with HIV per year -2006: CDC estimated that approximately 56,300 persons were newly infected with HIV -2015: CDC estimated 38,500 people were newly infected -african american: 16,200 -white: 10,200 -hispanic/latino: 10,000 -multiple races: 1,100 -asian: 740

Our mask for hearing imparied

-55% of communication is visual, traditional mask block faces and prevent our ability to see facial expressions and emotions, visual cues and communicate different mask options: -clear mask -see through mask

Dental hygiene care of hearing impaired

-determine the best mode of communication -hearing aides, don't touch them if they do not take them off -speak clearly and distinctly, slowly but not exaggerate words, not always louder -face the patient, watch the light overhead -turn sounds off in room: saliva ejector, tv -make sure to discuss before putting mask on signs you will use while wearing mask

Treatment planning considerations of HIV/AIDS

-determining the current CD4+ lymphocyte count and level of immunosuppression of the patient*** -the level of viral load may be related to susceptibility to opportunistic infections and rate of progression of AIDS -the dental provider should be knowledgeable about the presence and status of opportunistic infections and the medications that the patient may be taking for therapy or prophylaxis for such conditions -patients who are exposed to the AIDS virus and are HIV seropositive but asymptomatic may receive all indicated dental treatment >patients with a CD4+ cell count of more than 350/µL >standard precautions must be used for all patients -patients who are symptomatic for the early stage of AIDS >CD4+ cell count lower than 200 >increased susceptibility to opportunistic infection and may be medicated with prophylactic drugs -prevention of infection and excessive bleeding in patients with severe immunosuppression, neutropenia, and thrombocytopenia >prophylactic antibiotics in patients with CD4+ cell counts below 200/µL and /or severe neutropenia (neutrophil count lower than 500/µL) >severe thrombocytopenia: special measures (platelet replacement) before surgical procedures (including scaling and curettage) -patients may be medicated with drugs that are prophylactic for pneumocystis pneumonia, candidiasis, herpes simplex virus (HSV) or CMV infection, or other opportunistic diseases >care in prescribing other medications must be exercised with these, or any, medications after which the patient may experience adverse drug effects

Treatment modifications for parkinson's disease

-directly face patient when communicating (potential cognitive impairment) -dental treatment should be performed at max effect of parkinson's medications -tremors and sudden movements may warrant the use of soft arm restraints or sedation procedures

The mystery disease

-doctors in New York and California diagnosed 41 cases of a rare and often rapidly fatal form of cancer among homosexual men -treatment was chemotherapy -"the sudden appearance of the cancer, called Kaposi's Sarcoma, has prompted a medical investigation that experts say could have as much scientific as public health importance because of what it may teach about determining the causes of more common types of cancer"

Characteristics of hearing loss

-fails to respond to conversation -intentness: strained facial expression; stares at others -turns head to one side -gives unexpected answer unrelated to question -ask you to repeat what was said -unusual speech quality

Physical examination

-general appearance -weight -head and neck examination -skin and nails -face -eyes and nose -ears -neck -vital signs

Dementia

-general term for a decline in mental ability severe enough to interfere with daily life

Myocardial infarction (MI) aka HEART ATTACK

-happens as a result of no oxygen to a section of the heart (due to blocked arteries) -angina precedes most heart attacks dental considerations: -postpone treatment for at least 6 months*** -why we postpone: to avoid BACTERMIA, the heart muscle needs time to heal after an MI

Eyes and nose

-have patients remove eyeglasses to properly examine and palpate skin -hyperthyroidism may produce a characteristic lid retraction -xanthomas of the eyelids frequently are associated with hypercholesterolemia, as is arcus senilis in an older person -scleral yellowing may be caused by liver disease -reddening of the conjunctiva can result from the sjogren's syndrome (excessive dryness; autoimmune) or allergy

Dental management of HIV/AIDS

-health history, EO/IO exam, complete periodontal & dental examinations should be performed on all new patients -patients who know they are seropositive and those at high risk for infection may not answer questions honestly -caring, understanding verbal communication in a quiet, private location -referred for HIV testing, medical evaluation, other appropriate diagnostic procedures, & psychosocial intervention -dental treatment may not be withheld if the patient refuses to undergo testing for HIV exposure***

Risk of transmission from health care personnel

-in 1990, an HIV-infected Florida dentist transmitted, in some undetermined way, HIV infection to 6 patients -in 1997: HIV transmission involving dentistry came from Bucaramanga, Columbia, where 14 cases of HIV infection occurred among hemodialysis patients at a university hospital -transmission of the virus appeared to occur through contaminated dental instruments

Stress and anxiety reduction

-in all patients, especially those with medical problems, stress and anxiety control is important and helps reduce risk*** -establishing good rapport and trust is key -short morning appointments may be better tolerated than appointments later in the day >less stressed >medical conditions (diabetes, cardiovascular) better controlled >patients more likely to be compliant -oral premedication with an anxiolytic or sedative drug 1 hour before an appointment is recommended

Treatment of periodontal disease

-in patients with periodontal disease whose general health status is not clear, periodontal scaling for several teeth can be provided to allow assessment of tissue response and bleeding -adjunctive antibacterial measures may be required if the patient's CD4+ cell count is below 200/µL or if tissues remain unresponsive to routine therapy -linear gingival erythema, necrotizing ulcerative gingivitis, and necrotizing ulcerative periodontitis

Ryan white

-indiana teenager -contracted AIDS through a tainted hemophilia (blood disorder—blood cannot clot) treatment** -diagnosed with AIDS in 1984 -expelled from school because of the disease -died April 8, 1990 -Ryan white act: act provides grants to improve the quality and availability of care for individuals and families with HIV

HIV+ patient and HIV+ provider

-patients with AIDS who seek routine dental care cannot be declined treatment by the dentist*** -if the dentist and the patient agree, patient may be referred to another provider who is better suited to provide treatment -existing patient who develops AIDS must be treated by that dentist or receive a referral -the CDC and ADA recommend that infected dentists inform the patient of their HIV serostatus and should receive consent or refrain from performing invasive procedures

Dental hygiene care for blindness

-plan for treatment -patient familiarize with the office -short appointments -tell, feel, do -have brochures with brail -typodonts with different diseases to feel -audio tactile performance technique -show, feel instruments, suction

Ischemic heart disease

-primary etiology: atherosclerosis -result: reduction of blood supply to the myocardium risk factors: -inflammation -pathogenic microorganisms -periodontal disease -high lipids -tobacco -genetics possible manifestations/outcomes: -angina -myocardial infarction -congestive heart failure

Treatment of HIV/AIDS

-prophy/SRP -acyclovir suspension/ointment -benadryl elixir for pain -OTC drugs to relieve irritation & itchiness -avoid exposure to extreme cold/heat

Cochlear implant

-provide a sense of sound -profoundly deaf or severely hearing impaired -two parts: 1. external portion 2. internal portion (placed under the skin) -does not restore normal hearing

Communication with hearing impaired

-use visual aids as much as possible (brochures, before and after pictures, graphics) multiple methods of communication: -finger spelling, signing, speech reading -video relay service -using sign language to speak to a third party interpret via video -email, texting, writing things down in office interpreter WHEN? -when patient cannot read english -when extensive communication is needed -when patient cannot understand be sensitive to technology: -may not pick up on sounds meaning to start procedure or to stop a procedure -deaf individuals tend to be more sensitive to vibration

Early years of AIDs

-virus that causes acquired immune deficiency syndrome (AIDS) may have originated in Africa before 1970 -June 5, 1981—CDC reported 5 cases of Pneumocystis carinii (now jiroveci) pneumonia in young homosexual men in Los Angeles -pandemic of acquired immunodeficiency syndrome (AIDS) has started -1983: a retrovirus (later named the human immunodeficiency virus [HIV]) was isolated from a patient with AIDS

Vital signs

-vital signs consist of blood pressure, pulse, respiratory rate, temperature, height, and weight -height and weight can be determined by questioning the patient

Texas

-voluntary testing -HCW must provide patient notification and receive written consent prior to exposure-prone invasive procedure -restrictions based on type of practice, HIV status, and/or physical ability -must seek counsel from an expert review panel and must notify prospective patient of his status and obtained the patient's consent before the patient undergoes an exposure-prone procedure

Factor to consider for blindness

-when did the blindness occur? -intellectual capacity may differ depending when blindness occurred -blind children may speak later than sighted children = lack the opportunity to learn by imitation -parental or caregivers attitude influences the individual's adjustment -depression and feeling of helplessness may occur when adult looses their eyesight meeting the patient: -introduce yourself -ask if they want guidance -let them grab your elbow or shoulder -if child, have parent come back to operatory -have clear walk way to your chair if service dog: -do not distract a service or guide dog by touching or speaking to it -do not walk on the dog's left side -do not lead or grab the patient while dog is guiding -ask patient where the dog should stay smart cane: -visually impaired engineer named Kursat Ceylan invented the WeWALK smart cane -built in speakers -voice assistance -google maps -bluetooth system -high end sensors that alert the user through vibrations when above chest level obstacles are within proximity

HIV diagnoses by top 3 states as of 2017

1. Florida 2. California 3. Texas

The key to managing medially compromised patients is:

1. comprehensive evaluation 2. risk assessment why? -to determine whether a planned procedure can be safely tolerated -the fundamental question we should ask in these cases: >does the benefit of dental treatment outweigh the risk? examples: -nitrous vs epilepsy -perio infection vs pregnancy

Comprehensive evaluation

1. medical history: -vitals -relevant conditions/issues -triggers 2. medications/drugs: -current medications -drug use 3. EO/IO: -look for abnormal signs and symptoms 4. lab results: -obtain/review current lab results -i.e. diabetes (a1c), HIV (CD4 count) 5. medical consult: -complete medical consult if needed -be familiar with the list in the DH handbook

Oral complications and manifestations of multiple sclerosis

2-3% of MS patients have these complications: -dysarthria (speech articulation difficulty) -paresthesia (burning, tingling or numbness of extremities or face) -trigeminal neuralgia (chronic pain with trigeminal nerve) -mild stimulation to face (tooth brushing) may trigger a jolt of excruciating pain -relief of pain = carbamazepine or clonazepam (anti-seizure); or amitriptyline (anti-depressant since depression can be common with this); or surgery -myokymia (unusual muscle movements)

Visually impaired

28 million individuals who are visual impaired worldwide with 39 million blind and 246 with low vision -blindness: no perception of visual stimulation; lack ability to see -legally blind: less than 20/200 vision with corrective eyeglasses or having peripheral fields of no more than 20 degree diameter -color blindness: inability to distinguish between certain colors causes: age related: -diabetic retinopathy -macular degeneration -cataract/glaucoma/injuries children: -maternal infections: rubella, syphilis, toxoplasmosis -neoplasm, injuries -retinopathy of prematurity

Summary patient evaluation and risk assessment (ABC's)

A: -antibiotics -analgesics -anesthesia -allergies -anxiety B: -bleeding -breathing -blood pressure C: -chair position D: -drugs -devices E: -equipment -emergencies F: -follow-up

Neoplastic

abnormal and uncontrolled growth

Medical management of HIV/AIDS

medical management of the HIV-infected patient has four main treatment goals: -to reduce HIV-associated morbidity, and prolong the duration and quality of survival -to restore and preserve immunologic function -to maximally and durably suppress plasma HIV viral load -to prevent HIV transmission

Central nervous system (CNS) regions

motor: -walking -use of hands -incoordination -loss of balance -vertigo -tremor -paralysis of a limb -bowel/bladder incontinence -speech sensory: -loss of touch, pain, temperature and proprioception -fatigue -symptoms get worse with heat -problems with concentration *MRI scans for demyelinated regions (plaques) in white matter of the brain

Treatment of HIV/AIDS

treatment often is organized into 3 major areas: 1. antiretroviral therapy (ART) to achieve viral suppression and immune reconstitution -HAART: the use of at least three active antiretroviral medications -monitor for drug effectiveness, development of antiviral resistance, drug toxicity, and drug interactions 2. prophylaxis for opportunistic infections -vaccines, and stem cell transplantation 3. treatment of HIV-related complications

General appearance

visual inspection: -awareness and recognition of abnormal features or medical conditions that may influence dental care general appearance: -abnormal features can signal underlying systemic diseases -example: congenital methemoglobenemia which is elevated levels of methemoglobin in blood

Angina

what is it? -chest pain -can spread to shoulders, arms, neck, throat, jaw or back -can be mistaken for heartburn or gas etiology: -inadequate blood flow to heart (due to an underlying CVD) treatment: -angioplasty/stenting (balloon to open up narrowed artery) -bypass surgery (healthy arteries or veins taken from another part of body to bypass a blocked or narrowed artery) drug management: -nitroglycerin*** -most often used to treat angina -helps relax and widen blood vessels = increased blood flow to the heart

Types of oral cancer

-95% squamous cell carcinoma -5% other commonest sites of OC: -postero-lateral border of tongue -floor of the mouth -soft palate -gingiva -buccal and labial mucosa -hard palate oral cancer facts: -oral cancers make up 3% of all cancers in the United States (30% in India) -49,750 americans will be diagnosed with oral cancer -only 33% of oral and pharyngeal cancers were diagnosed at an early, localized stage (stage 1) in 2005-06 -5-year relative survival rate at early diagnosis (stage I and II) 58-72% -5-year survival at late diagnosis(stage III and IV) is 32-45 % -healthy people 2020 initiative seeks to increase the proportion of adults receiving annual oral and pharyngeal cancer screening -african american males and females have 40% and 18% more cancer deaths

Definition of HIV/AIDS

-AIDS is an infectious disease that is transmitted predominantly through intimate sexual contact and by parenteral means -although HIV has rarely been transmitted from patients to health care workers (HCW) this may occur -the patient with HIV infection or AIDS may be medically compromised and may need special dental management considerations

Etiology of HIV/AIDS

-AIDS is caused by the human immunodeficiency virus (HIV), a non-transforming retrovirus of the lentivirus family -there are two HIV subtypes: HIV-1 and HIV-2, and many strains of each -the cells most commonly infected are those with CD4+ receptors, including T helper lymphocytes (CD4+ cells) and macrophages

CDC and congress

-CDC became aware of a possible transmission of HIV from a Florida DDS to 6 of his patients in July 1990 -unclear whether transmission actually occurred -because of a CDC document, congress passed a law requiring states either to adopt the CDC guidelines or adopt similar guidelines of their own -most submitted their own guidelines

Kaposi Carcoma

-a malignant tumor of endothelial cells caused by human herpesvirus type 8 (HHV-8) -in these patients, kaposi sarcoma most often is disseminated throughout the body

Medical history

-a medical history must be taken for every patient two basic techniques: -interview the patient -questionnaire -many questionnaires are commercially available today, in both electronic and hard copy versions

Infective endocarditis

-a microbial infection of the heart valves or endocardium -streptococci and staphylococci are responsible for IE in most cases disease process: 1. bacteria released in bloodstream after instrumentation 2. attach to damaged heart valve or endocardium 3. inflammation 4. diminishes function of heart valve signs and symptoms: -fever -heart murmur -positive blood culture ***HIGH MORTALITY RATE

Screening tests of cancer

-a pathology report -diagnostic imaging such as x-rays, computed tomography (CT), positron emission test (PET), magnetic resonance imaging (MRI), and combined (PET/CT) -CBC -tumor marker tests -genetic testing

Stage 3 AIDS

-active TB -cryptococcal meningitis -toxo and histoplasmosis -pneumocystis (PC) pneumonia PCP -esophageal candidiasis -certain cancers, including Kaposi's sarcoma, Burkitt's and Non-Hodgkin's lymphoma, invasive cervical cancer -wasting (muscle and fat waste away) -progressive form of dementia

Lower respiratory tract disease

-acute bronchitis -pneumonia -tuberculosis (TB) -asthma -COPD -chronic bronchitis -emphysema -cystic fibrosis *usually more concerning that upper RTD

Risk factors of cancer

-age -tobacco -alcohol -cancer causing substances: aflatoxins, benzene, radon, asbestos, wood dust, arsenic, coal -chronic inflammation: IBD ulcerative colitis and crohn's disease -diet -hormones: estrogen -immunosuppression: transplant patients on immunosuppressive drugs and HIV -infectious agents: EBV, HIV, HPV -obesity -radiation -sunlight

Cardiac arrhythmias

-any variation in the normal heartbeat = change in rhythm, rate or conduction pattern of the heart factors that precipitate cardiac arrhythmias: -physical activity -anxiety -drugs -hypotension (vasoconstrictors in local anesthesia) -stress -fever stress and anxiety reduction: -establish good rapport -schedule short, morning appointments -ensure comfortable chair position -assess vital signs (pay attention to BP, pulse, and respiration) -pain control (nitrous oxide; local anesthesia: check for contraindications with other medications) anti-arrhythmia medications: -anticoagulants = risk for bleeding pacemakers: -implant that helps regulate an irregular heart rate (relies on electrical pulses) -antibiotic prophylaxis not indicated -potential interference with ultrasonic scalers and curing lights = DO NOT USE***

Oral complications of alzheimer's/dementia

-candidiasis -caries -aspiration pneumonia -increased dental problems -mucosal lesions -xerostomia -poor oral hygiene -periodontal disease

Skin and nails

-changes in the skin and nails frequently are associated with systemic disease*** -cyanosis can indicate cardiac or pulmonary insufficiency -yellowing may be caused by liver disease -pigmentation may be associated with hormonal abnormalities -petechiae or ecchymoses can be a sign of a blood dyscrasia or a bleeding disorder -dorsal surfaces of the hands are common sites for actinic keratosis and basal cell carcinomas -a raised, darkly pigmented lesion with irregular borders maybe a melanoma alterations in the fingernails: -clubbing (seen in cardiopulmonary insufficiency) -white discoloration (seen in cirrhosis) -yellowing (from malignancy) -splinter hemorrhages (from infective endocarditis)

Signs and symptoms of severe asthma attack

-chest tightness, sense of suffocation -ineffectiveness of bronchodilator -wheezing, coughing -flushed appearance, sweating -confusion due to lack of oxygen -dilated pupils -inability to complete a sentence in one breath -tachypnea -tachycardia preparing for a possible emergency: -recognize signs and symptoms -stop DH treatment -rule out foreign body obstruction -assist with patient's own bronchodilator inhaler -administer supplemental oxygen by nasal cannula -assist with the administration of subcutaneous injection or inhalation of epinephrine -monitor vital signs -call emergency medical service and initiate emergency procedures

Caring for patients with upper RPD

-delay treatment until patient is no longer infectious*** how do you know if a patient is no longer infectious?? -temperature returns to normal -throat/soft palate redness goes away

American with disabilities act (ADA)

-law in July 1990: prohibit discrimination and ensure people with disabilities have opportunities equal to everyone including employment opportunities purchase of goods and services, and access to state and local government programs and services -specifies that communications with individuals with hearing and vision impairments need to be as effective as communications with non-impaired people and appropriate auxiliary aids must be provided causes: -congenital (born) -acquired: inner ear infection, trauma, toxic effect of drugs statistics: -who: 360 million a form of hearing loss -aged 18-45 = 5% -aged 45-65 = begins to increase -aged 65-75 = 25% -aged 75+ = 50% -deaf: 4 out of 1,000 children are born deaf types: -conductive -sensorineural -mixed -central

What is cancer?

-long term, life changing diagnosis -changes occur at the gene level 1. inherited = 5-10% of all cancers 2. spontaneous 3. environmental -cells have lost ability to be regulated -cancer cells are less specialized compared to normal -genetic testing for risk -can hide from immune mechanism -malignant vs benign = ability to encroach surroundings and metastasize -metastasis: blood or lymphatic -angiogenesis -secondary tumors like the primary and retain identity -most deaths from metastasis

Hearing aids

-may request to remove the aide during the procedure -cost of device: average 5,000 for a pair -they amplify dental sounds -if seated on opposite side of aid: they may not hear sound -use touch cures: tap chin raise up/touch side of cheek turn this way -meniere disease: cause dizziness, slowly rise patient -talk in front of patient, not behind, remove mask -have patient put device back in so you can communicate with them

What is multiple sclerosis

-most common autoimmune disease of the nervous system -myelin sheath of neurons in the spinal tract become damaged = affects sensory and motor function clinical presentation: -first clinical signs = appear in young adulthood -clinical manifestations dependent on two things: 1. region of CNS (motor vs. sensory) 2. degree of myelin disruption -visual function (diplopia) and abnormal eye movement (nystagmus) are the most common manifestations*** MS clinical "attack": -"attack" described as when symptoms get worse attack symptoms include: -fatigue -dizziness -problems with balance/coordination -issues with vision, bladder, memory/concentration medical management: -corticosteroids (anti-inflammatory) -interferon beta-1a (Avonex) >reduces biologic factors that are involved in disease progression *MS management requires several other drugs = look out for drug-to-drug interactions dental management: -appropriate referral if clinical findings are suggestive of MS -postpone dental treatment if patient is experiencing an "attack" or "relapse" -optimal time for treatment = during remission -consider side effects of meds when formulating tx plan

Medical consultation

-necessary for symptomatic HIV-infected patients before surgical procedures are performed -current platelet count and white blood cell count should be available -any source of oral or dental infection should be eliminated in HIV-infected patients, who often require more frequent recall appointments for maintenance of periodontal health -daily use of chlorhexidine mouth rinse may be helpful -at UT, medical consult required for HIV-positive patients = we should assess WBC count and safety of patient before performing prophylaxis

Oral manifestations of hypertension

-none from hypertension ITSELF** oral manifestations due to drugs: -xerostomia -oral lesions from allergic or toxic reactions -lichenoid reactions -angioedema -persistent cough -gingival hyperplasia

What does this picture show?

-normal pigmentation of dopaminergic neurons in the substantia nigrans of a healthy patient (top)... ...depleted and depigmented dopaminergic neurons of the substantia nigrans in a patient who has parkinson's disease (bottom)

Current hypertension guideliness

-normal: <120/<80 mmHg -pre-hypertension: 120-129/<80 mmHg -stage 1: 130-139/80-89 mmHg -stage 2: ≥140/≥90 mmHg -patients with severe, uncontrolled hypertension (180/120 mmHg or higher) require urgent hospitalization

Previous hypertension guidelines (current clinic guidelines)

-normal: <120/<80 mmHg -pre-hypertension: 120-139/80-89 mmHg -stage 1: 140-159/90-99 mmHg -stage 2: ≥160/≥100 mmHg = medical consult required***

HIV rash symptoms

-occurs 2-4 weeks after infection -does not always occur -dark red/brown on light skin -dark purple/black on dark sin -mostly on face, hands, feet, trunk -blisters may occur in moist areas -folliculitis -may itch

Oral complications and manifestations

-oral lesions can be one of the early signs of HIV infection and risk for progression to AIDS -candidiasis of the oral mucosa (most common)*** -bluish-purple or red lesion(s) that on biopsy are identified as Kaposi sarcoma -hairy leukoplakia of the lateral borders of the tongue -hairy leukoplakia is a symptomatic, corrugated white lesion of the lateral borders of the tongue due to reactivation and replication of Epstein-Barr virus (EBV) >this lesion can appear in any patient who is immunosuppressed, irregardless of HIV status >histologic features include koilocytosis and hyperkeratotic, hairlike surface projections from the lesion >treatment is with antiviral agents -candidiasis, hairy leukoplakia, specific forms of periodontal disease (i.e., linear gingival erythema and necrotizing ulcerative periodontitis), Kaposi sarcoma, and non-Hodgkin lymphoma are believed to be strongly associated with HIV infection and can be a sign of treatment failure or disease progression -other oral conditions: HSV, herpes zoster, recurrent aphthous ulcerations, necrotizing stomatitis, oral warts, facial palsy, trigeminal neuropathy, salivary gland enlargement, xerostomia, and melanotic pigmentation the dentist should perform head, neck, and intraoral soft tissue examination on all patients: -white lesions in the mouth must be looked for specifically and appropriate steps taken to establish a diagnosis -if red or purple lesions are found that cannot be explained by history or proved by clinical observation, biopsy is indicated -persistent lymphadenopathy must be investigated by referral for medical evaluation, diagnosis, and treatment

States belief

-overall, states seemed to recognize that the risk of transmission from HCWs to patients was extremely low, esp. when universal precautions are followed -all states maintained a system of voluntary testing -mandatory disclosure was rejected as it could cause HCWs to avoid testing all together

Heart failure

-represents the end stage of one or more underlying cardiovascular problems -inability of the heart to function efficiently as a pump -high risk for acute failure, stroke or myocardial infarction (MI) -treatment is deferred until medical consultation from physician is obtained for treatment -generally heart failure patients are NOT candidates for elective dental treatment*** heart failure management: -short, stress-free appointments -patient chair position: semi-supine, upright (heart failure patients commonly have pulmonary edema; upright chair helps with breathing) -avoid epinephrine if patient is on digoxin (epi can initiate arrhythmias) -if epi is used, limit to 2 carpules***

Clinical laboratory tests

-results are usually reported with normal values -helps detect suspected diseases (e.g., diabetes, infection, bleeding disorders, malignancy) -screening high-risk patients for undetected disease (e.g., diabetes, AIDS, chronic kidney disease)

Upper respiratory tract disease

-rhinitis (common cold) -influenza (flu) -sinusitis -pharyngitis/tonsilitis

Treatment modifications

-simple modifications in dental treatment can be made in an effort to reduce risk to the patient -risk is always increased when a medically compromised patient is treated -the goal is to reduce that risk as much as possible -the dentist should always try to anticipate possible urgencies or emergencies and be prepared to manage them as they arise

Slowdown of AIDS epidemic

-since the introduction of protease inhibitors in 1996 and the advent of highly active antiretroviral therapy (HAART), the epidemic of AIDS in the United States has slowed and stabilized -estimated annual HIV infections in the US has declined 8% from 2010 -> 2015

Restrictions

-some required that HIV-positive HCWs stop performing invasive procedures until they seek the advice of the committee -other states made the decision to seek advice of the committee more voluntary -committees were to consider: >HCWs skill and technique >type of procedure -HCWs ability to adhere to universal precautions -physical and mental status of the HCW

After a cancer diagnosis

-staging: extent and spread different types: -where the tumor is located in the body -the cell type (such as adenocarcinoma or squamous cell carcinoma) -the size of the tumor -spread to nearby lymph nodes -distant metastasis -tumor grade, which refers to how abnormal the cancer cells look and how likely the tumor is to grow and spread

Oral complications and manifestations of parkinson's disease

-staring, drooling, decreased blinking and swallowing -muscle rigidity makes oral hygiene care difficult what can we do to help? -frequent recall visits -collis curve toothbrush -salivary substitutes (xerostomia is a side effect of medications) -topical fluoride

Ears

-the ears should be inspected for gouty tophi in the helix or antihelix -an earlobe crease may be an indicator of coronary artery disease -malignant or premalignant lesions (e.g., skin cancer) may be found in or around the ears

Transmission of HIV/AIDS

-the most common method of sexual transmission: intercourse in MSM (male homosexual intercourse) -the second most common: heterosexual transmission (but accounts for 80% of the world's HIV infections) -the third most common mode of transmission in US: injection drug use -blood, semen, breast milk, and vaginal secretions: associated with transmission of the virus -HIV has been found in saliva, and transmission by transfer of saliva possibly contaminated with blood has been reported from providing pre-masticated food from HIV-infected patents to infants

Neck

-the neck should be inspected for enlargement and asymmetry -bilateral palpation of the thyroid gland should be performed -depending on location and consistency, enlargement may be caused by goiter, infection, cysts, enlarged lymph nodes, malignancy, or vascular deformities

Occupational exposure to HIV

-the risk of HIV transmission from infected patients to HCW is very low -reportedly about 3 of every 1000 cases (0.3%) in which a needle stick or other sharp instrument transmitted blood from patient to HCW -the risk of infection from a needle stick is 3% for hepatitis C and is 30% for hepatitis B -after a needle stick, the rate of transmission of HIV can be reduced by post-exposure prophylaxis (PEP) -the CDC recommends PEP ASAP after exposure -PEP should be continued for 4 weeks, during which time the exposed clinician should be provided expert consultation, and follow-up monitoring for compliance, adverse events, and possible seroconversion -tests for seroconversion: at 3, 6, and 12 months***

Face

-the shape and symmetry of the face are abnormal in a variety of syndromes and conditions well-recognized examples: -coarse and enlarged features of acromegaly -buffalo hump in cushing's syndrome -unilateral paralysis of bell's palsy

Care management for patients with infective endocarditis

-thorough medical history -medical clearance needed to use ANY instrumentation (explorer and probe included) -pre-medication recommended*** DH care: -OHI -instrumentation: have patient brush, floss and rinse thoroughly with CHx or listerine prior to instrumentation to reduce bacteremia -ask if pre-med was taken and what time (should be ~1-2 hours prior to appt time)

Physician referral and consultation

-to determine the need for treatment modifications -contacting patient's physician for consultation or referral purposes may be warranted -request for information should be made in writing by letter or fax if possible; however, a phone call may be more expedient or convenient -these communications should be entered into the patient's chart***

Alzheimer's disease

-type of dementia -contributes to issues with memory, thinking and behavior incidence and prevalence: -prevalence increases with age -by age 65, 7% have dementia -by age 85, more than 40% will have it etiology of alzheimer's and dementia: -possibly due to the decrease and function of acetylcholine (AcH): a neurotransmitter involved in memory and learning -unidentified factors trigger plaque formation = destroys cholinergic neurons risk factors: -age -family -history -genetics -ApoE4: is a risk gene that increases risk of alzheimer's (does not guarantee it will happen, even if you get a copy from each parent) dental management: -POSITIVE communication (patient and family) -healthcare decisions = patient vs. family -3-month recall -fluoride varnish -OHI -adjustment of prostheses as needed advanced alzheimer's patients may be: -anxious -hostile -uncooperative -do shorter appointments -simple DH treatment -sedation for complex dental treatment

Hypertension

abnormal elevation of arterial blood pressure aka "silent killer" risk factors: -tobacco -heredity -overweight -race (african americans -> caucasian) -excessive salt use in diet -men more common than women -age: increases with age (levels off at 40 and then rises with older age) -environment: stress contributes to HBP clinical symptoms of hypertension: -occipital headaches and irritability -dizziness -ringing ears -tingling of extremities -visual disturbances -weakness drug interactions with hypertension: -use caution with vasoconstrictors (epinephrine) = could spike BP -most HBP medications lead to orthostatic hypotension -erythromycin and clarithromycin can heighten the hypotensive effective of medications

Caring for Patients with lower RTD

acute bronchitis: -postpone treatment until it resolves pneumonia: -postpone treatment until it resolves tuberculosis (active): -do not treat, treatment should be performed in a HOSPITAL asthma: before treatment: -have bronchodilator/oxygen available -schedule morning appointments*** -provide stress-free environment -medical consult for unstable/severe asthma -some patients are less stressed during late mornings/early afternoons = ASK what works best for them during treatment: -use sulfite-free local anesthesia if needed (without epinephrine)*** -fluoride treatment -prevent triggering hypersensitive airway (proper use of cotton rolls, suction tip) after treatment: -rinse with water after using inhaler (decreases oral candidiasis)*** -tylenol is the BEST analgesic choice if needed -aspirin or NSAIDs may trigger attack = avoid

Caring for Patients with lower RTD: chronic obstructive pulmonary disease

before treatment: -assess breathing difficulty -chair positioning: upright or semi-upright to facilitate breathing during treatment: -use antimicrobial mouth rinse -avoid power-driven scalers (cavitron, piezo) -administer local anesthetic without epinephrine -avoid nitrous oxide with patients who have severe COPD and emphysema after treatment: -tobacco cessation -discuss oral-systemic link/risk between periodontitis, oral cancer and COPD -frequent recall **smoking causes 90% of COPD cases *contamination of tubing/breathing apparatus; these patients depend on low blood oxygen concentration to initiate breathing

Categories of cancer

carcinoma: -are cancers of the epithelial cells and named depending on the cells they arise in -squamous cell -basal cell -adenocarcinoma in fluid filled epithelia cell/glandular cells (salivary glands, breast, colon, prostate) sarcomas -are cancers in bone and soft tissue (osteosarcoma, kaposi sarcoma) leukemia lymphomas from lymphocytes multiple melanoma from plasma cells in bone marrow melanoma

Patient evaluation and risk assessment

dentistry today is different than 1-2 decades ago: -longer lifespan -medical treatment available for disorders that were fatal only a few years ago dental providers should be knowledgeable about a wide range of medical conditions: -most chronic conditions require an alteration to treatment and/or recall for dental visits

Signs and symptoms of active tuberculosis

early onset: -low-grade fever -non-productive cough (3+ weeks) -fatigue -unexplained weight loss -sweating at night later onset: -fever -chills -persistent cough with purulent sputum -hemoptysis -hoarseness -chest pain -dyspnea infection control measures for TB: -update medical history -recognize signs and symptoms -defer dental treatment if patient is active -for active TB, refer to urgent dental care to a healthcare facility

Clinical presentation of HIV/AIDS

first 2-6 weeks after initial infection: -more than 50% of patients develop an acute flu-like syndrome marked by viremia that may last 10 to 14 days -symptomatic persons often develop: lymphadenopathy, fever, pharyngitis, and a skin rash -infected persons do not display circulation antibodies until the 6th week to 6th month -most patients show antibodies by 6th month of infection -CD4+ and CD8+ cell counts should be performed at time of HIV diagnosis and every 3-4 months

Signs and symptoms of alzheimer's/dementia

first signs: -loss of recent memory, orientation or language -change in personality (apathy) -cognitive changes: >finance tracking >following instructions at work >driving >shopping >housekeeping middle stages: -unable to work -easily lost and confused -daily supervision needed -language, motor and thought processes are impaired advanced stages: -muscle rigidity -mute -incontinence -bedridden -generalized seizures -death usually occurs a result of malnutrition, secondary infection or CVD

Parkinson's disease

neurologic disorder that affects MOVEMENT etiology: -death and depletion of neurons that make dopamine** clinical presentation: -resting tremor -muscle rigidity -slow movement -expressionless facial appearance -dementia (25%) -pain -orthostatic hypotension -bowel/bladder dysfunction (50% of patients) -cognitive memory impairment -mood disturbances, insomnia and fatigue (40% of patient) dental management: -minimize the adverse outcomes of muscle rigidity and tremor -assess patient's TB technique through demo -tools: >collis curve toothbrush >mechanical toothbrush -assisted brushing -chlorhexidine rinses avoid drug interactions: -limit epinephrine to 2 carpules containing 1:100,000 epi in patients who take COMT inhibitors -erythromycin should not be given to patients who take Mirapex (dopamine agonist) -anti-parkinson's drugs work as CNS depressants, be cautious with sedatives -orthostatic hypotension*** chair management: -assist patient to and from chair to avoid falls -incline/decline chair slowly

Risk assessment

one widely used method of expressing medical risk is the american society of anesthesiologists (ASA) physical classification system -ASA I: normal healthy patient -ASA II: patient with mild systemic disease -ASA III: patient with significant or severe systemic disease that limits daily activity -ASA IV: patient with severe systemic disease that is a constant threat to life or that requires intensive therapy -ASA V: the category for a moribund patient

Treatment plan modifications of multiple sclerosis

stable disease: -routine care recommended advanced disease: -assistance with dental chair transfer -may have difficulty with oral hygiene -poor prognosis for reconstructive or prosthetic procedures -short, morning appointments

The CDC defines THREE stages of HIV infection

stage 1: -generally begins immediately after HIV exposure and may last for years stage 2: -progressive immunosuppression and symptomatic disease: >persistent generalized lymphadenopathy (PGL) >fungal, vaginal, herpetic infections >oral hairy leukoplakia stage 3: -persons with AIDS can demonstrate a variety of immunosuppression-related diseases

Laboratory findings

stage 1: lab confirmation, no AIDS conditions -CD4+ >or = 500 cells/μl and CD8+ >or = 29 stage 2: no AIDS conditions -CD4+ 200-499 cells/μl and CD8+ 14-28 stage 3: AIDS defining conditions supersede blood counts*** -CD4+ <200 cells/μl and CD8+ <14

Anaplastic

the ability to divide rapidly with cells having no resemblance to normal cells

Pathophysiology of cancer

the genetic changes affect 3 main gene types 1. proto-oncogenes (respiratory normal growth and division) vs oncogene 2. tumor suppressor genes controls cell growth and division 3. DNA repair genes.(like the name implies, repairs damaged DNA) -these changes are sometimes called "drivers" of cancer -scientists can characterize cancer by the genetic alterations U.S. and worldwide statistics: -prevalence 2016 there were 15.5 million US -1.7 million incidence 2018 (CDC) -mortality 599K USA 2018 (CDC) -mortality 8.2 million cancer-related deaths worldwide

Metastasis

the spread of cancer cells from the place where they first formed to another part of the body -benign -malignant