Medical Issues and Reverse Medical Histories

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Medical Issues and Reverse Medical Histories

• JOE ALAMAT DDS, MD
• SUMMIT ORAL AND MAXILLOFACIAL SURGERY
• dralamat_at_yahoo.com
• [phone])

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Medication List

• Learn to decipher the patients medical history
  through medication lists.
• Know why they are on the medications
• What precautions should be taken
• Learn to think like the PCP.

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Topics that will be covered

• CVS
• Diabetes
• Immunocompromised
• Pregnancy
• Oral Cancer
• Osteoporosis

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Cardiovascular diseases

• Two disease entities will be covered
• Hypertension
• Myocardial infarction

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Traditional Vs Functional Medicine

• Traditional medicine teaches us that hypertension
  is a disease that is diagnosed by elevated
  systolic and or diastolic pressures. Treatment is
  focused on decreasing the blood pressure readings
  by medications.
• Integrative medicine recognizes that hypertension
  is a symptom of underlying endothelial
  dysfunction secondary to inflammation and
  increased oxidative stress. Treats patients by
  exercise, diet, micronutrient replacement such as
  Zn, Vit C, in addition to medications

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• Preload
• Afterload
• Ejection fraction

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HTN

• Patient presents for routine check up
• Bp is 175/95
• HTN confirmed three time at least a week apart
  140/90 or use ambulatory blood pressure monitors.
  
• Single diastolic reading of 110 is confirmation
  of HTN

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Complications of HTN

• The problems associated with HTN or increased
  afterload
• Heart has to pump with more force to overcome the
  pressure
• Cardiac hypertrophy and eventually left
  ventricular dysfunction develops
• End organ damage (fundoscopic, renal, brain) all
  associated with vascular damage

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• How can we decrease the pressure
• in this closed system
• Decrease pump strength
• Increase the volume in arteries
• Increase volume in the veins
• Decrease fluid in the system

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Medications To Treat HTN

• Beta blockers (olols) decrease pump strength and
  speed
• Diuretics (Lasix, Lozol, HCTZ) decrease fluid in
  the system
• Ace inhibitors (prils) decrease the fluid
  resorption in the kidneys and prevents
  angiotensin from developing

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Medications To Treat HTN

• Calcium channel blockers (norvasc etc) increase
  the volume in the arteries
• ARBs block the vasoconstrictive effects of
  angiotensin
• Alpha antagonists (Terazosin) relax arteries and
  increase the volume of the arteries
• Centrally acting (Clonidine) decrease sympathetic
  outflow on the CVS

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Mild HTN easily controlled based on prescription
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Moderate to Severe Hypertension based on
prescription
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How would you address a clearance

• The more meds a patient is on to control HTN, the
  more labile the HTN
• Avoid excessive epi
• Measure the BP
• Aspirate when injecting
• Calm environment

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Always Check the BP
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MI

• You are a cardiologist called to the cath lab for
  a patient with an STEMI. You determine that the
  LAD is occluded and decide to place a stent.
• What are the next steps of medical management?
• 6-8 Meds are always initially used.

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Mi Management

• Decrease the preload ( blood return to heart)
  with nitrates like nitrodur

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MI Management

• Decrease the afterload (so the heart is not
  pumping against high pressure so as not to stress
  the heart) BP meds
• ARB
• Ace inhibitor
• Beta blocker
• etc

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Mi Management

• Increase blood flow to the myocardium by using
  nitrates

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Mi Management

• Improve the lipid profile by using statins

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Lipid profile drugs

• Cholesterol lowering medications
• Lipitor (went generic)
• Zocor
• They are both statins decrease production of
  cholesterol
• Zetia decreases absorption
• Zocor and Zetia called Vytorin
• Others are Crestor and Niaspan and Tricor

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Mi Management

• Anticoagulate to prevent reocclusion of the stent
  and dissolve or prevent thrombotic emboli
  .(antiplatelets)
• Aspirin
• Plavix

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Anticoagulant

• Coumadin inhibits factors 10, 9, 7 and 2 from
  forming in the liver. Half life 20-60hours
• Pradaxa (dabigatran) reversibly and directly
  inhibits thrombin. Half life is 12-17 hours. No
  INR required.
• Xarelto (rivaroxaban) is a factor Xa inhibitor.
  Half life 5-9 hours.

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• ADA council on scientific affairs stated that
  antiplatelet and anticoagulant meds rarely need
  to be discontinued prior to most dental
  procedures. The risk for thromboembolic events
  exceeds the risk of bleeding.

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Never stop Plavix or ASA after a recent MI
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MI management

• Regulate the speed of the heart so that
  arrhythmias do not develop.

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Beta Blockers

• Used to treat HTN, angina and Migraines
• Work on the beta receptors and block them, unlike
  asthma medications that stimulate the receptors
• Metoprolol (Lopressor) is a cardioselective med

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MI management

• Amiodarone for ventricular tachycardia

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Red Flags

• Coumadin s/p MI indicates significant ventricular
  dysfunction secondary to ischemia.
• Amiodarone suggests that the patient has a
  history of dangerous ventricular tachycardia and
  rhythm

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Dental clearance

• Increased risk of problems in the first 6 months
  status post MI
• Do Not stop Plavix or aspirin or coumadin
• No epi
• No Nsaids
• Ask if patient gets shortness of
  breath.(Functional Capacity)

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Diabetes

• Fasting Glucose
• 99 or below is normal
• 100 to 125 Pre-diabetes impaired fasting glucose
• 126 or above diabetes
• Random glucose above 200
• Type I autoimmune
• Type two insulin resistance

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Metabolic Syndrome

• The dominant underlying risk factors for this
  syndrome appear to be abdominal obesity and
  insulin resistance.
• Insulin resistance is a generalized metabolic
  disorder, in which the body cant use insulin
  efficiently.
• This is why the metabolic syndrome is also called
  the insulin resistance syndrome

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Metabolic Syndrome

• Some people are genetically predisposed to
  insulin resistance.
• Acquired factors, such as excess body fat and
  physical inactivity, can elicit insulin
  resistance and the metabolic syndrome in these
  people.
• Most people with insulin resistance have
  abdominal obesity.

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Diagnosis is three or more

• Elevated waist circumferenceMen  Equal to or
  greater than 40 inches (102 cm)Women  Equal to
  or greater than 35 inches (88 cm)
• Elevated triglyceridesEqual to or greater than
  150 mg/dL
• Reduced HDL (good) cholesterolMen  Less than
  40 mg/dLWomen  Less than 50 mg/dL
• Elevated blood pressureEqual to or greater than
  130/85 mm Hg
• Elevated fasting glucoseEqual to or greater
  than 100 mg/dL

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Manifestations of Metabolic Syndrome
Skin Tags
Acanthosis Nigrans
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Type of Obesity
Central Adiposity
Generalized adiposity
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Diabetes meds

• Actos, Avandia
• Decreases insulin resistance
• Lantus
• Long acting injected insulin
• Byetta
• Increases insulin secretion
• Metformin
• Decreases absorption

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Treatment of diabetes

• Oral Hypoglycemic
• Insulin if resistant or level high
• Weight modification
• ACE inhibitors if protein is in the urine to
  protect the kidneys
• Usually associated with hypertriglyceridemia
• Usually treated with Niaspan

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Functional Medicine

• In addition to Medications, supplements are used.
  
• Zinc
• Chromium
• ALA
• Vit D (sequestered in fat)
• CoQ10
• Omega 3
• Sleep
• Decrease stress levels
• Low Glycemic Index foods

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Glycemic Index

• It measures how fast food raises the sugar level
  in the blood
• Glucose has a GI of 100. shoot for foods less
  than 55
• E.g.
• Bagel 72
• Cornflakes 93 Coco Pops 73
• Rice Cakes 82 Pretzels 83
• Ice cream 57
• Apple 39
• Fruit roll Ups 99 M peanut 33

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Dental clearance issues

• Minimize NSAIDs
• Watch for hypoglycemia
• Watch carefully for infections( use cidal meds
  such as PCN Doc)
• Ask about their HBA1C

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Immunocompromised patients

• Patients that fall in this category are numerous.
  Among them are
• those on steroids over 20 of prednisone daily.
• Organ transplant patients
• Patients on chemotherapy
• Patients taking DMARDS( disease modifying anti
  rheumatic drugs)

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Transplant Patients

• Liver
• function is assessed by the PT which measures
  1972. Ask about increased bleeding, bilirubin
  etc. If tests are okay then treat as an
  immunocompromised patient
• Kidney
• ask about the bun and creatinin. Should be 10,
  and 1 respectively. If tests okay treat as
  immunocompromised patient
• Heart
• Ask about EF and CHF.

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Transplant Patients

• Some of their meds include
• Azathioprine
• Cellcept avoid motrin
• Cyclosporine avoid emycin, motrin
• Immuran
• Prograf avoid emycin, motrin
• GVHD lichenoid reactions

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DMARDS

• Are used for autoimmune diseases such as chrons
  disease, psoriasis, rheumatoid arthritis etc.
• Newer ones include TNF Inhibitors. These can be
  Mabs such as
• Adalimumab (Humira)
• Golimumab (Simponi)
• Infliximab (Remicaide)
• Or fusion proteins such as
• Etanercept (Enbrel)

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What are the MABS

• They are drugs that are Monoclonal AntiBodies.
• They are from animals
• Rats- AMAB
• Hamster-EMAB
• Primate- IMAB
• Mouse- OMAB
• Human-UMAB
• From human and animal mixed thus they are called
  chimeric
• XIMAB (Constant part is human)
• ZUMAB (variable is human)
• They are used in Cancer treatment, autoimmune
  disease, osteoporosis, and many other uses.

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Immunocompromised patients

• Beware of infections consider premedication
• Be aware of transient bacteremia from poor oral
  hygiene
• Do not give NSAIDS
• Do not give erythromycin or Z packs
• DOC is tylenol or Ultram
• Pen vk is DOC
• Clinadamycin if that doesnt work

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Pregnancy

• Not a contraindication to treatment.
• Important points are pen vk, clindamycin are
  allowed
• Tylenol3, tylenol, vicodin are all permitted
• Absolutely no NSAIDS or steroids.
• Steroids are teratogenic
• NSAIDS shut down the ductus arterosis.
• Minimize epi.
• That is what is in a clearance.

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Cancer Patients

• Prior to undergoing chemo treat any potential
  source of infection. Be aggressive
• During chemo therapy treat only emergencies.
  They are at high risk of fulminant infections and
  surgery sites heal very slowly
• Use cidal antibiotics such as penicillin as first
  therapy
• Arimidex or tamoxifen are used for ongoing breast
  CA treatment
• Leupron for prostate CA

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Cancer Patients

• Extract any tooth that is in the line of the beam
  if radiation therapy is to be done always at a
  risk for ORN
• Fluoride trays must be made
• Cleanings and exam every three months.
• Note about HPV (Cetiximab or Erbitux)

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Osteoporosis

• In osteoporosis, the bone mineral density (BMD)
  is reduced and bone microarchitecture
  deteriorates.
•  Osteoporosis is defined by the World health
  organization (WHO) as a bone mineral density of
  2.5 standard deviations or more below the mean
  peak bone mass (average of young, healthy adults)
  as measured by dual energy X ray absorptiometry

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Calcium Metabolism
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Osteoporosis Medications
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Bisphosphonates

• At this time, FDA believes that the benefits of
  oral bisphosphonate drugs in reducing the risk of
  serious fractures in people with osteoporosis
  continue to outweigh their potential risks.
• The agencys analysis, which found little if any
  benefit from the drugs after three to five years
  of use

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Bisphosphonates

• Actonel (risedronate) PO
• Aredia (pamidronate) IV
• Boniva (ibandronate) IV
• Fosamax (alendronate)
• Reclast (zolendronate) once a year for
  osteoporosis IV
• Skelid (tiludronate) PO
• Zometa (zolendronate) Once a month for cancer IV

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Osteoporosis drug may reduce colon cancer risk

• Mayo clinic health letter 2011 Jul29(7)4.

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Oral Bisphosphonates and the Risk of Esophageal
Cancer

• Exposure to bisphosphonates may be associated
  with an increased risk of esophageal cancer. More
  studies are needed to confirm the relationship.
• Aliment Pharmacology Ther. 2012 Oct36(8)708-16.
  doi 10.1111/apt.12041. Epub 2012 Sep 11.

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Bisphosphonate Use and Gastrointestinal
Tract Cancer Risk

• Oral bisphosphonate use had no significant effect
  on gastrointestinal cancer risk. However, this
  finding should be validated in randomized
  controlled trials with long-term follow-up.
• World J Gastroenterology 2012 Oct
  2818(40)5779-88. doi 10.3748/wjg.v18.i40.5779.

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Prolia (Denusomab)

• Prolia( denosumab)fully human monoclonal antibody
  denosumab inhibits osteoclast development,
  function, and survival
• Inhibits the RANKL protein that acts as the
  primary signal for bone removal

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SERMS

• Viviant(bazedoxifene) and Evista(raloxifene) are
  oral selective estrogen receptor
  modulators (SERM) that have estrogenic actions on
  bone and anti-estrogenic actions on the uterus
  and breast.
• Estrogen is responsible for increased BMD

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Forteo

• Forteo( teriparatide) parathyroid hormone
  analogue
• PTH increases serum calcium, partially
  accomplishing this by increasing bone resorption.
  Thus, chronically elevated PTH will deplete bone
  stores. However, intermittent exposure to PTH
  will activate osteoblasts more than osteoclasts.
  Thus, once-daily injections of teriparatide have
  a net effect of stimulating new bone formation
  leading to increased bone mineral density

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Tylenol VS NSAIDs which is better

• They both work well
• But avoid NSAIDs in older patients due to kidney
  and GI concerns.
• Avoid in diabetics and renal patients.
• Contraindicated in pregnancy

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RED FLAGS

• Shortness of breath
• BP above 200/100
• Wheezing that doesnt resolve after two puffs of
  albuterol
• Cirrhosis patients
• Patients on amiodarone do not give epi
• Transplant patients do not give motrin or
  erythromycin

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Red Flags

• MI in the last 6 months
• Pregnant patients are not red flags