Review of Systems II

1
Review of Systems II

• Gastrointestinal, Hepatic, Neurologic Systems,
  Extremities

2
GI System

• Peptic Ulcer Disease
• Inflammatory bowel disease
• Pseudomembranous colitis

3
GI System

• The Dentists must
• Monitor patient symptoms
• Be aware of drugs that interact with GI
  medications or aggravate the medical condition
• Be familiar with oral patterns of medical disease

4
GI System

• Peptic Ulcer Disease
• Affects about 15 of the population
• Occurs in patients 30-50 yrs of age
• Etiology Aggressive factors
• H. pylori
• Acid hypersecretion
• Cigarette smoking
• Use of NSAIDS
• Psychological physical stress

5
GI System

• Peptic Ulcer Disease
• Etiology Defensive factors
• Mucous gel
• Bicarbonate
• Prostaglandins
• Mucosal blood flow
• Signs Symptoms
• Epigastric pain-longstanding described as
  burning, gnawing

6
GI System

• Treatment
• Antisecretory drug in combination with
  antibiotics
• Dental concerns
• Systemic antibiotics for peptic ulcer disease may
  result in fungal overgrowth (candidiasis) in the
  oral cavity
• Vascular malformations of the lip
• Enamel erosion (as in bulemia)

7
GI System Dental Management

• Review medications for NSAIDS, oral
  anticoagulants, ASA, ETOH which can cause GI
  bleeding
• If active disease refer to physician
• Care in monitoring drug therapy
• Avoid prescribing ASA, NSAIDS
• Selecting an analgesic
• Consider patient risk factors for GI bleeding
  provide lowest dose for effect

8
GI System Dental Management

• Care in monitoring drug therapy
• Acid blocking drugs (cimetidine) decrease the
  metabolism of certain dental drugs
• Diazepam
• Lidocaine
• Tricyclic antidepressants
• May require dosage adjustment

9
Inflammatory Bowel Disease

• 2 Disease entities
• Crohns Disease
• Transmural process-affecting entire bowel wall
  may produce ulcerations at any point of the
  alimentary canal
• Ulcerative colitis
• Mucosal disease limited to the large intestine
  and rectum
• Inflammatory diseases of unknown etiology

10
Inflammatory Bowel Disease

• Ulcerative colitis
• Attacks of diarrhea
• Rectal bleeding
• Abdominal cramps
• Crohns Disease
• Diarrhea
• Abdominal pain
• Anorexia
• Fever, malaise
• Arthritis
• Weight loss

11
Dental Implications IBD

• Aphthous-like lesions affect 20 of Ulcerative
  Colitis pts
• In Crohns disease, may be atypical mucosal
  ulcerations diffuse swelling of the lips
  cheeks.

12
Pseudomembranous Colitis

• Severe fatal form of colitis due to overgrowth
  of Clostridium difficile
• Potent enterotoxins induce colitis
• Can be caused by broad spectrum antibiotics which
  wipe out competitive anaerobic gut bacteria

13
Pseudomembranous ColitisDental concerns

• Certain systemic antibiotics are associated w/
  risk of pseudomembranous colitis in elderly,
  debilitated patients
• Lincomycin, clindamycin, ampicillin,
  cephalosporins
• No reports of pseudomembranous colitis exist
  following short term use of clindamycin for AHA
  propylactic regimen

14
Liver Disease

• Liver plays important role in metabolism
• Secretion of bile - fat absorption
• Conversion of glucose to glycogen
• Excretion of bilirubin
• Liver abnormalities can lead to impaired
  metabolism of
• Amino acids, ammonia, protein, carbohydrates,
  lipids
• Liver provides synthesis of coagulation factors
  drug metabolism

15
Signs of Liver Disease
Jaundice Yellow skin conjunctiva
Tender, swollen liver Accumulation of fluids cirrhosis
Peripheral edema Accumulation of fluid due to blockage in the portal circulation
Ascites Accumulation of fluid in abdomen due to blocked portal circulation
Hepatic encephalopathy Confusion, coma due to accumulation of waste
Spider angiomas Arteriovenous anastomoses (face, neck, upper thorax)
16
Signs of Liver Disease
Palmar erythema Blotchy erythema caused by vasodilation
Bilirubinemia Impaired conjugation of bilirubin
Inc. enzyme levels ALT, AST, Alk. Phos, GGTP from damaged hepatocytes
Prolonged Prothrombin Time Insufficient coagulation factors /or vitamin K deficiency
17
Liver Disease

• Alcoholic liver disease
• Fatty infiltrate of liver
• Alcoholic hepatitis
• cirrhosis
• Hepatitis
• Inflammation of the liver from infectious or
  non-infectious process

18
Alcoholic liver disease

• Due to large, chronic alcohol consumption
• Patient likely to be malnourished, folic acid
  deficiency, B 12, anemia, decreased immune
  function
• Can lead to hepatic failure
• Malnutrition
• Weight loss
• Protein deficiency including coagulation factors
  (bleeding tendency)
• Impaired urea synthesis, glucose metabolism
• Endocrine disturbances
• Encephalopathy
• Renal failure
• Portal hypertension
• jaundice

19
Alcoholic liver diseaseSystemic
complications Oral complications

• Unexplained injuries
• Memory deficits
• Slurred speech
• Spider angiomas
• Jaundice
• Ascites
• Peripheral edema
• Ecchymoses, bleeding
• Social problems

• POH
• Oral neglect
• Angular cheilosis
• Candidiasis
• Gingival bleeding
• Oral cancer
• Petechiae, ecchymoses
• Xerostomia
• Parotid gland enlargmt
• Attrition
• bruxism

20
Painless enlargement of parotid
21
Alcoholic liver disease

• Dental Implications
• Liver enzyme induction CNS effects of alcohol
  can require increased amounts of local anesthetic
  or additional anxiolytic procedure be used.
• May require additional time at appt
• Care in using drugs that are metabolized by liver

22
Alcoholic liver disease

• Dental Implications
• Impaired gustatory function
• Nutritional deficiencies glossitis,
  loss of tongue papillae
• Vitamin K deficiency, bleeding problems may
  impact surgery
• Risk for oral cancer
• Routine soft tissue examination each 6 months

23
Alcoholic liver disease

• Dental Implications Summary
• Look for
• Bleeding tendencies
• Unpredictable drug metabolism of certain drugs
• Risk or spread of infection
• Laboratory tests that may be helpful in
  diagnosing liver disease
• CBC differential, AST ALT, bleeding time,
  thrombin time, prothrombin time

24
Dental Drugs Metabolized in Liver

• Most LA are safe in liver disease if used in
  appropriate amounts
• Analgesics
• Aspirin
• Acetaminophen
• Codeine
• Demerol
• Ibuprofen
• limit dose if severe liver dx, or if bleeding
  abnormalities
• limit dose if severe liver dx, encephalopathy,
  or taken w/ alcohol

25
Dental Drugs Metabolized in Liver

• Antibiotics
• Ampicillin
• Tetracycline
• Metronidazole
• Vancomycin
• avoid if severe liver disease present

26
Hepatitis

• Acute viral hepatitis is most common form of
  infectious hepatitis
• Types A, B, C, D, E
• Viruses behave differently

27
Hepatitis
Agent Transmission Carrier of cases
HAV Fecal-oral No 47
HBV Parenteral sexual, perinatal Yes 27
HCV Parenteral sexual, perinatal Yes 36,000 cases/yr
HDV Parenteral sexual, perinatal Yes 7,500 cases/yr
HEV Fecal-oral No 1-5
28
Hepatitis A

• Transmission occurs by fecal contamination of
  food water
• Sources
• Contaminated wells, restaurants, raw shellfish
• Occurs primarily in children and young adults
• Mild in severity

29
Hepatitis B

• Transmission is primarily by percutaneous and
  permucosal exposures
• Transfusion of infective blood, needle sharing,
  tatooing, body piercing
• Indirect percutaneous through small cuts in the
  skin
• Absorption of infective serum through mucosal
  surfaces (mouth, eye)
• Absorption of infective secretion (saliva, semen)
• Transfer via inanimate surfaces/vectors

30
Hepatitis B

• Lifetime risk is low, but certain groups are at
  higher risk
• Dental personnel, health care workers
• Refugees from certain countries
• Hemodialysis patients,
• drug users
• Homosexual males
• Heterosexuals with multiple partners
• Recipients of blood transfusions
• Can develop chronic hepatitis, hepatocellular
  carcinoma

31
Hepatitis C

• Similar to HBV in characteristics
• 60-90 of cases involve transmission via blood
  or blood products
• 70 90 of adults with disease become chronic
  carriers
• 25 die from the disease
• Risk of future development of hepatocellular
  carcinoma
• No vaccine

32
Signs Symptoms of Hepatitis

• 3 phases of acute illness
• Prodromal
• Abdominal pain, anorexia, nausea, vomiting,
  fatigue, myalgia, malaise, fever
• Icteric phase
• Jaundice, GI symptoms may increase, hepatomegaly,
  splenomegaly
• Convalescent phase
• Symptoms disappear, but hepatomegaly, abnormal
  liver function tests may persist
• Recovery months

33
Dental Management of Hepatitis Patients

• Id patients who are carriers HBV, HCV, HDV
  important yet difficult
• Id who may have active disease or history
• physician consultation
• Treat all patients as if they are potentially
  infectious
• Use universal precautions/vaccinated

34
Dental Management of Hepatitis Patients

• No dental treatment other than urgent/emergency
  care for pts with active hepatitis unless patient
  is clinically biochemically recovered
• If surgery need evaluation of coagulation
  status
• Your medical history may not tell you the
  complete story

35
Neurologic Disease

• Epilepsy
• Cerebral Vascular Accident
• Transient Ischemic Attacks
• Headaches
• Paralysis

36
Epilepsy

• Group of disorders with chronic, recurrent,
  paroxysmal changes in neurologic function caused
  by abnormal/spontaneous electrical activity in
  the brain.
• May be convulsive or involve changes emotional,
  cognitive, sensory status
• Most common in children who often outgrow them

37
Etiology

• Head trauma
• Developmental abnormalities
• Hypoglycemia
• Neoplasm
• Febrile illness
• Often unknown

38
Signs Symptoms

• Tonic-Clonic convulsions
• Aura occurs in 1/3 of patients
• Patient looses consciousness, generalized muscle
  rigidity, pupil dilation, breathing may stop,
  beating movements of head, arms, incontinence
  then muscle relaxation and return to
  consciousness
• May have stupor, headache, confusion, depression

39
Medical Management

• Long-term drug management
• Phenytoin (dilantin)
• Carbamzepine (tegretol)
• Valproic acid
• All elevate seizure threshold of motor cortex
  neurons
• Surgical interventions
• Last resort tx in severe cases

40
Dental Management

• First step Identify the patient
• History and ask questions
• Seizure history
• Type of seizures
• Age at onset
• Medications
• Frequency of physician visits
• Degree of control
• Frequency of seizures
• Date of last seizure
• Any know precipitating factors
• Injuries

41
Dental Management

• Most patients are able to be controlled w
  medication
• History level of seizure activity may suggest
  non-compliance w drug therapy
• Or change in condition
• Both of which require physician consultation

42
Dental Management

• Drugs used in the treatment of seizure disorders
  may have a narrow therapeutic range
• Drugs may cause an oral side-effect gingival
  hyperplasia (42 )
• Check drug interactions seizure tx drugs have
  important interactions
• Be prepared to manage grand mal seizure

43
Gingival Hyperplasia
44
Dental Management

• Be prepared to manage grand mal seizure
• Ligated mouth prop
• Ask the patient to inform you if have aura
• Manage the seizure
• Clear area
• Turn the patient to the side to avoid aspiration
• Do not use padded tongue blade
• Passively restrain

45
Dental Management

• After the seizure
• Examine for traumatic injuries
• Discontinue treatment
• Arrange for patient transport

46
Cerebral Vascular Accident

• Serious/fatal sudden interruption of oxygenated
  blood to the brain which leads to focal necrosis
  of brain tissue
• 3rd most common cause of death in US
• 600,000 people annually suffer strokes
• Types
• Hemorrhagic
• Embolic
• thrombotic

47
Cerebral Vascular Accident

• Etiology
• Cerbrovascular disease
• Atherosclerosis
• Hypertensive vascular disease
• Cardiac pathology
• Heart attack
• Atrial fibrillation

48
Cerebral Vascular Accident

• Risk Factors
• Previous MI
• TIA
• Previous stroke
• High dietary fat /obesity
• Physical inactivity
• Uncontrolled hypertension
• Diabetes mellitus

49
Cerebral Vascular Accident

• If a patient survives it is likely that they
  would have a disability
• 10 recover with no disability
• 50 have mild residual disability
• 15-30 are disabled and require special services
• 10-20 require institutionalization
• Return to function is unpredictable, takes place
  slowly over months

50
Residual Damage
51
Cerebral Vascular AccidentRight-sided
damage Left-sided damage

• Paralysis
• Spatial-perceptual deficits
• Thought impaired
• Quick impulsive behavior
• Difficulty performing tasks
• Memory deficits
• Neglect of left side

• Paralysis
• Language speech difficulties
• Decreased auditory memory
• Slow, cautious, disorganized behavior
• Language based memory deficits
• anxiety

52
Transient Ischemic Attack

• Reversible temporary interruption in blood supply
  to localized areas of the brain
• May precede CVA
• Lasts few minutes to 24 hrs
• Patients may have muscle weakness, numbness,
  tingling of face and extremities

53
Dental Management of CVA Pt

• Deferment of elective dental treatment for 6
  months post stroke
• Risk of re-stroking (14 within one year)
• Some patients are put on preventive anticoagulant
  therapy require monitoring of status prior to
  surgical procedures
• Coumadin
• Patients may also take anti-platelet drugs

54
Dental Management of CVA Pt

• Short mid-morning appointments
• Reduce stress
• Assist in transfer
• Dont over-estimate patients ability
• Communications skills needed
• Monitor BP
• Patients have feelings of grief, loss
  depression, so think compassionately

55
Dental Management of CVA Pt

• If patients have physical limitations
• Oral hygiene may be difficult
• Consider adjuncts for oral care
• Electric sonic toothbrushes
• Therapeutic gels/rinses
• Plan restorations with ease of cleansability

56
Parkinsons Disease

• Progressive neurodegenerative disease of neurons
  that produce dopamine
• Results in motor disturbances
• Tremor, stiffness, shuffling gait, diminished
  facial expression
• Affects about 1 million US individuals
• Men slightly more affected than women

57
Parkinsons Disease

• Etiology unknown
• Associated factors
• Mutation in chromosome 4
• Stroke
• Brain tumor
• Head injury
• Exposure to manganese, mercury, carbon disulfide,
  some agricultural herbicides

58
Parkinsons Disease Signs Symptoms

• Resting tremor pill rolling
• Muscle rigidity
• Slow movements bradykinesia
• Facial passiveness
• Stooped posture
• Cogwheel rigidity
• unsteadiness

59
Parkinsons Disease Signs Symptoms

• Pain
• Orthostatic hypotension
• Bowel bladder dysfunction
• Cognitive dysfunction/dementia
• Mood disorders

60
Parkinsons Disease Oral Signs Symptoms

• Complaints of drooling dry mouth due to
  swallowing difficulties/medication, respectively
• Difficulty maintaining oral hygiene
• Consider adjunctive oral care aids
• Difficulty opening due to muscle rigidity and
  tremor

61
Clinical Features of Parkinsons Dx
62
Dental Management

• Primary goals
• Minimizing adverse effects of muscle rigidity,
  tremor
• Avoiding drug interactions
• Care to avoid falls from the dental chair due to
  orthostatic hypotension
• Protect the airway! Due not lay patient supine
  when placing restorations

63
Drugs used to treat Parkinsons Dx

• Anticholinergic Artane, Cogentin
• Dopamine Precursor Levodopa/Carbidopa
• Dopamine Agonist Parlodel, Permax
• Catechol-O-methyltransferase Inhibitors
• - Tasmar, Comtan
• Monoamine Oxidase B Inhibitor Selegiline
• Neurotransmitter inhibitor Amantadine

64
Joint Disease
65
Joint Disease

• Years of wear tear, complication of chronic
  rheumatoid arthritis articular
  joint destruction
• Joint must be replaced with synthetic materials
• Question Are patients with prosthetic joints at
  risk for PJI (Prosthetic Joint Infections) with
  dental procedures that cause bleeding?
• Controversy remains--- Where is the evidence?

66
Joint Disease

• Literature Review 281 isolates from 6 studies
  of PJI cause by hematogenous spread
• 66 PJI caused by staphyloccus
• 4.9 PJI caused by viridans strep
• 2.1 PJI caused by peptostrep
• Vast majority of PJI are caused by wound
  infections or skin infections

67
Joint Disease

• 1997 ADA/AAOS advisory statement
• Scientific evidence does not support the need for
  antibiotic prophylaxis for dental procedures to
  prevent PJI
• Antibiotic premedication NOT indicated for pts
  with pins, plates, screws for most patients
  with prosthetic joint replacement

68
Joint Disease

• Antibiotic premedication is recommended for
• High risk patients with prosthetic joints
• Immunocompromised Patients
• Rheumatoid arthritis, Systemic lupus, drug or
  radiation induced immunosuppression nursing
  home residents
• Other patients
• Insulin-dependent (type I) diabetics
• First 2 yrs following joint replacement
• Previous prosthetic joint infections
• Malnourishment
• Hemophilia

69
Recommended Regimens

• Patients not allergic to Penicillin
• Cephalexin, Cephadine or Amoxicillin
• 2.0 grams orally 1 hour before dental procedure
• Not allergic to Penicillin unable to take oral
  medication
• Cefazolin 1m0 gram or ampicillin 2.0 grams IM or
  IV 1 hour before dental procedure

70
Recommended Regimens

• Patients allergic to Penicillin
• 600 mg Clindamycin orally 1 hour before the
  dental procedure
• Patients allergic to penicillin unable to take
  oral mediation
• 600 mg Clindamycin IV 1 hour before dental
  procedures

71
Dental Considerations

• If pt. has RA TMJ involvement occurs in 45-75
  of patients
• Extensive dental treatment or long appointments
  contraindicated
• Patient may have difficulty with maintaining oral
  hygiene
• Consider adjunctive aids to oral care
• Prevention is key

72
Systemic Lupus Erythematosus

• SLE (arthritis is most common manifestation)
• Autoimmune disease of unknown etiology
• Genetic immune abnormalities with triggers
• Stress, infectious agents, diet, toxins, drugs,
  sunlight
• Immune complexes deposited in variety of organs
  kidney, lung, brain, GI tract, lymphatics, eye

73
Butterfly facial rash of SLE
74
Dental Management of SLE

• Physician consultation
• Drug considerations/drug side-effects
• Patients may have low white blood cell count
  (leukopenia) which may have infection potential,
  especially if patient is on corticosteroids or
  cytotoxic medications
• Abnormal bleeding thrombocytopenia
• Patients may have cardiac valvular disorders

75
Dental Management of SLE

• Patients may have oral lesions, ulcerations
  resemble lichen planus or leukoplakia
• Xerostomia, hyposalivation, dysgeusia, glossodynia