Wednesday, May 30, 2012

Hemotologic DIsorders

Kyung-Hong Cal Kim

Hemotologic DIsorders

Anemia
-Reduction of the RBC volume, hemoglobin concentration below normal range (12-18g/100ml)
-Inadequate production: Congenital pure red cell anemia (Diamond-Blackfan syndrome), chronic renal disease, infection, inflammation, cancer megaloblastic anemia
-Increased destruction: intrinsic abnormality (hereditary spherocytosis), enzymatic defects (G6PD deficiency), defects in hemoglobin synthesis (sickle cell disease, thalassemia)
-Extracellular abnormalities: infection (mononucleosis), autoimmune (SLE), transfusion reactions


Bleeding Disorders
-Clotting factor deficiencies
-Thrombocytopenia
-Platelet dysfunction

Oral Evaluation
-Hx of frequent nose bleeds, heavy menstrual flow, easy bruisability, excessive bleeding following surgery, family hx of bleeding disorders, known hx of bleeding disorders, current medication
-Petechiae and ecchymosis, generalized spontaneous gingival hemorrhage
-PT, PTT, platelet count

Management
Low risk (normal PT, PTT and platelet count and bleeding time)
-Treat as normal
Moderate risk (juvenile RA on chronic high dose aspirin therapy)
-Documented approval by physician,
-Hemophilia treated with appropriate factor replacement (40-50% of normal for restoration, 80-100% for extractions)
-Mild to moderate factor VIII treated with DDAVP
-Amicar or Cyclokapron (anti-fibrinolytic supplement) following tx
High risk (known bleeding disorders, abnormal coagulation tests)
-Hematology consult
-Hospitalization may be indicated
-Nasotracheal intubation may be contraindicated

Tuesday, May 29, 2012

Special Patients

Resident: Swan SPECIAL PATIENTS

I.  Autism and ASD
-4 to 1 boys over girls. Disorder where children undergo abnormal brain development from early infancy.
Spectrum:
A.  Autism-severe language problems, lack of interest in others, repetitive behaviors, irrational routines
B. Asperger-strong verbal skills, trouble with social situations, obsessive interests
C.  PDD (Pervasive Developmental Disorder)-"atypical autism," kids have less severe social impairments
D. CDD (Childhood disintegrative disorder)-normal development 2-4 years, then symptoms develop
E. Rett Disorder: similar pattern to CDD but occurs earlier and in girls mostly

Early indicators:  doesn't respond to name, acts as though were deaf, doesn't smile socially, doesn't point or gesture by age 1, no babbling
Common Meds: Tegretol, Clonidine, Prozac, Ritalin

Dental Management:
-No specific anomalies, but occlusal attrition common due to bruxing
-desensitization (least anxiety-producing to most), lots of positive reinforcement, physical restraint if needed, keep sentences short/simple, possibly use music as an aid, keep environment familiar-same room, same people present if possible.

II. ADHD
-most common neurobehavioral disorder in children, typically presenting by age 7.  9% males, 3% females
-main symptoms: inattention, hyperactivity, impulsivity; school difficulties, difficult interpersonal relationships, low self esteem, aggression
-Diagnosis: specific criteria in DSM-IV, present in two or more settings
-Tx: target outcomes to guide management coordinated between child, family, school, physician
     *Stimulant meds: Methylphenidate (Ritalin), dextroamphetamine (Adderall)
           -xerostomia possible side effect
     *Behavioral therapy at home and at school
Dental: Discuss tx and behavior management in detail with parents. Review meds. Pt takes meds day of appt. Lots of positive reinforcement


III. Seizure Disorders
-Spontaneous uncontrollable excessive discharge of cerebral neurons
-Epilepsy=recurrent seizures
-seizures before age 2 usually caused by high fevers
-Classification: Partial, generalized.  (Most common generalized is tonic-clonic)
-hx for dental patients: type, frequency, last seizure, triggers, meds, diet
-medical management: anti-convulsant meds, ketogenic diet, surgery
Dental precautions: meds can have side effects (gingival hyperplasia, gingival bleeding, xerostomia)
   -xylocaine decreases seizure threshold
Management of a seizure: note when it begins, STAY CALM, move everyone away, position pt to prevent injury (nothing in mouth, supine), post ictal airway support, suction airway, vitals

IV. Neural Tube Defects
-Causes: folic acid deficiency (most common), IDDM, maternal epilepsy meds, maternal obesity
-Types: Anencephaly (absence of forebrain/cerebrum-pt dies shortly after birth); encephalocele (neural tube doesn't close completely=groove down ML of upper skull
-Spina Bifida:  3 Types
1. Spina Bifida Oculta: most common, mildest-outer part of some vertebrae doesn't form
2. Meningocele: least common, meninges pushed out through cleft in vertebrae(covered by skin)
3. Myelomeningocele: most severe form, meninges protrudes as a sac through vertebrae
-paralysis, incontinence, hydrocephalus (90%)
Tx: infant surgery (doesn't correct nerve damage), shunt for hydrocephalus (SBE prophylaxis for VA or VV shunt), latex allergy precautions

V. Cerebral Palsy
-malfunction of motor centers/pathways of brain
-paralysis, weakness, incoordination-no cure
-types: spastic (stiff/rigid muscles, lack of control), dyskinetic (athetoid-slow, writhing, involuntary movements), Ataxic (tremors/uncoordinated voluntary movements), Mixed
-Clinical manifestations: MR (60%), seizure disorders (30-50%), sensory/speech deficits
-Oral findings: Perio disease, increased caries, malocclusions, bruxism, increased gag reflex and drooling, mouth breathing
Tx: calm/supportive tx environment, pt in center of dental chair, tx in wheelchair if necessary, use limb supports, mouth props, GA for extensive work


Endocrine Disorders

AAPD Handbook: Endocrine Disorders
Resident: Matthew Freitas

ENDOCRINE DISORDERS:

I. PANCREAS: Produces enzymes (exocrine) and secretes hormones (endocrine)
1. Diabetes Mellitus- hyperglycemia
 -glucose concentration >= 200mg/dl, fasting plasma glucose >= 126mg/dl, 2hr plasma glucose >= 200mg/dl
-defect in insulin secretion, action, or both
-type 1: destruction of beta cells in pancreas (immune-mediated or idiopathic), most common type in children, polyuria, polydipsia, weight loss, requires insulin injections
-type II: insulin resistance, frequently overweight, diet and lifestyle modification
-type III: diabetes due to etiologies (genetic defects, disease, drug induced, infection, etc)
-type IV: gestational, temporary, 2-5% of pregnancies
-Dental findings: xerostomia, increased caries, oral candidiasis, burning mouth/tongue, taste alteration, increased perio, poor wound healing, acetone breath, odontalgia
-Considerations: good medical hx, AM and short appts, eat meals, minimize stress, consider adjustment of insulin dosage, consult physician


II. THYROID GLAND: Secretes thyroxine (T4), triiodothyronine (T3), Calcitonin
1. Hypothyroidism- insufficient thyroid hormones, Primary and Secondary, cold, dry skin and brittle hair, hair loss, generalized edema, weight gain, slow wound healing, pitting of skin
-Dental findings: enlarged tongue, delayed tooth development and eruption, malocclusion, gingival edema, delayed skeletal development, protruding tongue and thick lips
-Dental considerations: sensitivity to stress, sedatives, and opioids
2. Hyperthyroidism- excess release of thyroid hormone, Graves disease, rapid heart rate, intense fatigue, hot body temp, nervousness, jitters, irritability
-Dental findings: osteoporosis of alveolar bone, increase in caries and perio risk, teeth and jaw develop more rapidly, premature loss of primary teeth and early eruption of permanent teeth
-Dental considerations: avoid use of epi or pressor amines in poorly controlled

III. ADRENAL GLAND: Produces steroid hormones- glucocorticoids (cortisol), mineralocorticoids (aldosterone), androgens
1. Adrenal insufficiency (AI)- deficiency of hormones at the adrenal gland (Addison disease- primary AI), fatigue, loss of appetite, darkening of skin, GI symptoms, hypotension, muscle/joint pain, salt craving
2. Secondary and Tertiary AI- problem at the pituitary gland and hypothalamus, symptoms are similar to primary AI, hypoglycemia
3. Adrenal crisis- adrenal insufficiency, dehydration, hypotension, imbalances of sodium and potassium, shock is the main symptom
-Dental findings: hyperpigmentation of skin and mucous membrane, delayed healing, infection
4. Hyperadrenalism (Cushing syndrome)- glucocorticoid excess, round/red face, buffalo hump, protruding abdomen, high BP, weakness, thirst, increased urination
-Dental findings: osteoporosis, delayed wound healing, susceptible to fractures, implants contraindicated

IV. PARATHYROID GLAND: produces PTH, regulates serum calcium
1. Hyperparathyroidism- osteoporosis, renal stones, gastric distress, Reckinghausen disease
-Dental findings: loss of lamina dura, decreased density of bony trabecula (ground glass), central giant cell granuloma
2. Hypoparathyroidism- Digeorge syndrome, idiopathic atrophy
-Dental findings: tetany, paresthesia of distal extremities, laryngospasm, circumoral paresthesia, enamel hypoplasia, delayed eruption, enamel attrition

V. PITUITARY GLAND: produces hormones (connects endocrine with CNS)- thyrotropin, gonadotropins, growth hormone, corticotropin, prolactin hormone
1. Hypopituitarism- dwarfism, fatigue, decreased appetite, cold, abdominal pain, blurred vision, loss of body hair, short stature, infertility
-Dental findings: decreased linear facial measurements, delayed tooth eruption, smaller mandible, hypodontia
2. Hyperpituitarism- Acromegaly and gigantism

Sunday, May 27, 2012

Childhood Cancer


AAPD Handbook: Childhood Cancer
Resident: Elliot Chiu

Most common childhood cancers 0-19 years of age: Leukemia and CNS cancer
-Leukemia – 2 major types
            1. Acute Lymphoblastic Leukemia: 75%
            2. Acute Non-Lymphocytic Leukemia: 19%
            -Highest incidence rate in children 1-4 years
            -Overall survival rate: 80% for ALL, 50% for ANLL

Other childhood cancers
-Lymphomas
-3rd most common form of childhood cancer
-Hodgkin’s and non-Hodgkins
-Sympathetic nervous system tumors
          -97% were neuroblastomas
-Soft tissue sarcomas
          -Rhabdomyosarcoma – most common soft tissue sarcoma
-Renal tumors
-Malignant bone tumors
          -Osteosarcoma, Ewing’s sarcoma

Oral complications of chemotherapy and radiotherapy
-Mucositis, secondary infections, salivary gland dysfunction, bleeding, mucosal/muscular fibrosis, osteoradionecrosis, soft tissue necrosis, TMD, craniofacial and dental developmental problems, oral graft vs host disease

Oral and dental management
-All dental care should be completed before therapy starts. When that is not feasible, prioritize procedures and place temporary restorations until the patient is stable.
-ENDO: extract primary teeth if prognosis of pulpotomy/pulpectomy is questionable
-ORTHO: if poor OH, remove appliances
-PERIO: extract 3rd molars to prevent pericoronitis
-OMFS: extractions done  at least 7-10 days prior

Hematological considerations:
-ANC > 1,000: no need for antibiotic prophylaxis
-ANC < 1,000: defer elective dental care until ANC rises, discuss antibiotic prophylaxis with PCP
-Platelet count >75,000: no additional support needed
-Platelet count 40,000 – 75,000: platelet transfusions may be considered
-Platelet count <40,000: defer care unless emergency cases

Dental considerations during immunosuppression periods
-OHI, diet, fluoride, lip care, education, emergency dental care only, oral mucosal infections, oral bleeding, xerostomia,  dental sensitivity/pain, trismus

Tuesday, May 22, 2012

New Morbidities- AAPD Handbook

New Morbidities
Jessica Wilson
Pregnancy:
5-8% teenage population. "Term" labor: 36-42 weeks. Low birth weight: <2500g.
common oral findings: pregnancy gingivitis, perio disease, pregnancy granuloma, dental erosion and sensitivity, dental caries, and increased tooth mobility.
Pregnancy itself is no reason to postpone routine and necessary dental care. Emergency/needed tx ideal between 14-20th week as the patient may have morning sickness in the first trimester and physical discomfort in third.
Decreasing maternal cariogenic bacterial load with use of fluoride, chlorhexadine and xylitol important, as well as infant oral health anticipatory guidence.
FDA category B drugs may be used during pregnancy: Penicillin, amoxicillin, clindamycin, acetaminophen, ibuprofen and 2% lido w/ 1:100,000 epi.
Obesity & Eating Disorders:
Obesity: BMI > 95th percentile. Overweight: BMI >85th percentile.
Health related concerns: type II diabetes, perio disease, hypertension, cardiovascular disease, psychological distress, respiratory, orthopedic and hepatic problems.
Eating disorders: ~90% female, highest mortality rate of any mental illness.
Anorexia nervosa characterized by BMI <5%. Many anorexia patients brush their teeth vigorously to remove any trace of calorie intake which may cause abrasion of enamel, cervical cementum and gingival recession. Bulimia patients may present with dental erosion, sharp incisal edges, parotid gland swelling with apparently normal salivary flow, thermal sensitivity, callus formation and soft palate injury from induced vomiting.
Abused, Neglect, Missing/Exploited Children:
Epidemiology: Annual incidence reported cases ~3million. Non-reported to reported is 100:1. 1,000-2,000 die annually in the US. 50% children under 7 years old. 30-65% injuries are to the head/neck area.
Dental/Oral findings: bite marks, burns, fractured or displaced teeth, jaw fractures, multiple injuries in various stages of healing, oral/peri-oral gonorrhea.
Substance Abuse:
Overindulgence in and dependence on a stimulant, depressant, chemical substance, herb or fungus leading to effects that are detrimental to an individual’s health or welfare of others. Approximately 50% of US high school students will experiment with at least one illicit drug before graduating. Using alcohol and tobacco at a young age increases risk of using other drugs later.
Youth at risk: family history of substance abuse, depressed, low self-esteem, those who feel that they do not fit in.
Warning signs: fatigue, lasting cough, personality change, irritability, low self-esteem, withdrawing from family, dramatic change in dress and appearance.
Tobacco:
Almost 25% children are current smokers by the time they leave high school (males>females). 10% male high school boys report past-month use of spit tobacco. 90% of adult smokers began before the age of 18. Leukoplakia, which can lead to oral cancer, occurs in more than half of all spit tobacco users in the first 3 years of use.
5As Intervention to treat Tobacco Dependence:
Anticipate by educating parents about smoking.
Ask if they have tried tobacco.
Advise about short-term consequences, to be prepared to refuse tobacco and to stop if they have started.
Assess readiness to stop.
Arrange for follow-up, offer tobacco-free messages at each visit.

Infectious Disease


Infectious Disease
Prevention-Immunization against common infectious disease is recommended
Bacterial Infections:
Impetigo-Superficial Infection of the skin; Tiny pustules that eventually rupture; condition is generally self limiting and complications are uncommon; Treatment can be topical antiobiotics and cleansing of the wounds and improved hygiene; Dental treatment should be deferred until resolution.

Bacterial Pharyngitis-inflammation of the tonsils and pillars; Most common in ages 5-15; Onset accompanied by abdominal pain; vomiting, fever, with sore throat developing later; Lasts 5-7 days and spontaneously resolves; Can be treated with pen VK; Dental treatment should be deferred until resolved

Gonococcal Stomatitis- STI which can cause pharyngitis in some cases; Common in ages 15-24; Oral lesions resolve with antibiotic treatment; Complications include damage to reproductive systems; Dental provider must rule out sexual abuse and refer to proper authorities for diagnosis and treatment

Syphilis-STI most common in young adults in overcrowded populations; Risk factors include drug use and sexual activity; Highly sensitive to penicillin; Oral findings include chancer and congenital abnormalities
                Primary-painless chancre at site of exposure-3 weeks incubation
                Secondary-constitutional symptoms, rash, renal, hepatic, ophthalmologic signs. Meningitis
                Tertiay-Gummas form and neuronal involvement;
                Congenital-rhinitis, condyloma lata,Hutchinsons’s incisors and Mulberry molars

Tuberculosis-Chronic Granulomatous infection of lung; Occurs in all ages but elderly and children are the most susceptible; diagnosed with chest xray and skin test; Treated with standard TB regiment; Complications include ulcers, granulomas, and osteomyelitis; Dental treatment should be deferred until TB is controlled

Viral Infections:
Hand-Foot-and Mouth-Caused by coxsackie A16; incubates for 3-6 days; symptoms are fever, malaise,  sore mouth and vesicles with rapid ulceration in mouth and on skin; Treatment is supportive care-hygiene and hydration; Defer dental treatment until resolved

Herpangina-Coxsackie A virus; Affects infants and young children; high fever, oropharyngeal vesicles and ulcerations; self-limiting; treatment is supportive care with fever-reducing meds and fluids; defer dental treatment

Acute nasopharyngitis-common cold; most common infectious disease; more than 150 different virus variants identified; clinical course 7-14 days; complications include otitis media, croup, and bronchiolitis; treatment is rest and supportive care; Defer dental treatment until resolved

Influenza-Acute respitodays,ry tract infection; 3 types of viruses-highly contagious; onset in 2-3 days after exposure; symptoms are varies and include vomiting; diarrhea; cough; headache; fatigue; Prevented by vaccine; Treatment is supportive with fever reducing meds and supportive care

Acute Herpetic Gingivostomatitis- HSV-1 virus; Typically first exposure to the virus; Ranges from subclinical to severe; Oral findings are dominated by vesicles that rupture to form shallow ulcers; Pain, fever, and dehydration common; Self limiting in 7-14 days.  Supportive treatment with Tylenol for fever and pain and cool liquids to combat dehydration.

Recurrent HSV-Reactivation of latent disease present in trigeminal ganglia; often triggered by stress; fever; sunlight or hormonal imbalance; Vesicles rupture and heal by brownish crusted lesion; transmission to hands or fingers possible; supportive care is treatment; Topical antivirals can shorten healing time; Dental treatment should be deferred

Chickenpox-Primarily children under 10 years of age; incubation period is 13-17 days; symptoms are malaise and low fever, crops of small red papules which rupture and become crusted; self-limiting for healthy individuals; Prevention is by vaccination; Treatment is supportive to maintain hydration and reduce fever; Dental treatment should be deferred

Mononucleosis-Epstein-Barr virus-Incubationi for 30-50 days; fatigue, malaise, sore throat, fever, headache, nausea and abdominal pain; diagnosis through blood markers; Self-limiting; Treatment is supportive with rest and NSAIDS for fever and discomfot

Hep B-Primarily spread through blood exposure; most common in young adults; incubation period of 2-5 months; Symptoms are anorexia, nausea, vomiting, malaise, cough, jaundice, and abdominal pain, Prognosis is favorable; infants are vaccinated; Treatment is supportive care

Condyloma Acuminatum-Multiple papillary or sessile areas of epithelial hyperplasia occurring on the genitals or oral mucosa; commonly acquired through oral-genital contact; Recurrence is common; Treatment by surgical excision or cryotherapy; Lesions should be documented and sexual abuse should be ruled out

HIV-Primary route of pediatric infection is maternal transmission; Major target is CD4 lymphocyte; Severity of disease is monitored by CD4 count; symptoms depend on severity of immunosupression and can include chronic infections and susceptibility to fungal infections; treatment is HAART-Highly active antiretroviral therapy;  oral manifestations are common candida infections, hairy leukoplakia; hodgkins lymphoma and kaposis sarcoma;  TX for candidiasis is nystatin suspension and topical imidazole for angular chelitis; HSV treated with acyclovir; HPV treated with excision and biopsy; Consultation with physician is important and frequent recall is recommended

Fungal infections
Candidiasis-Complications are rare in immunocompetent  patients; Can present as thrush involving the lips, tongue, gingiva, or palate; oral burning and refusal to eat are common; treated with topical or systemic nystatin suspension;  HIV must be ruled out when seen in children;  Defer dental treatment until resolved.

Parasitic Infections-Lice-Parasite involing the scalp; Feed on blood; pruritis is the first sign of infestation; children in daycare or school are common carriers; treatment is hair creams and shampoos.  Dental treatment should be deferred until resolved

Monday, May 21, 2012

Cardiovascular Diseases

-         Tetralogy of Fallot: VSD, pulmonic stenosis, aorta overrides VSD, hypertrophy of the right ventricle
-         Syndromes associated with cardiac defects: Down and Turner syndromes, OI, Marfan syndrome, Ehler-Danlos syndrome
-         Symptoms of congenital heart disease: dyspnea, cyanosis, polycythemia (increase in RBC), clubbing of toes or fingers, syncope, coma, weakness, murmur.
-         Rheumatic Fever: Acute inflammatory condition that develops sometimes as a complication of group A streptococcal infections (ex. strep throat infections) or as a result of an autoimmune reaction
o       Sx: arthritis, carditis, chorea (abnormal involuntary movement), erythema marginatum (pink rings on trunks and limbs), and subcutaneous nodules
o       Tx: Penicillin g benzathine, codeine, salicylates
-         Rheumatic Heart Disease: Cardiac damage that can result from rheumatic fever.
o       Damage most commonly occurs to the mitral or aortic valve
-         Cardiac Arrhythmias: Variation in the normal rhythm, rate, or conduction of heart beat.
o       Bradycardia <60 beats/min. Tachycardia >120 beats/min (in children)
o       Minimize use of epi, avoid GA, avoid electric equipment that may interfere with a pacemaker
-         Hypertensive Heart Disease:
o       Essential hypertension is defined as systolic pressure exceeding the 95 percentile for gender, age, and height in children after 3 readings in a non-stressful situation.
o       Secondary hypertension is caused by underlying disorder.
-         CHF: Inability of the heart to deliver an adequate supply of blood to meet metabolic demands.
-         Infective Endocarditis: Microbial infection of the heart valves or endocardium, occurring in multiple forms, often seen in patients with congenital heart defects of the heart.
o       Acute: Sudden onset, can be fatal in less than 6 weeks, Staphylococcus aureus
o       Subacute: Slower onset, Streptococcus viridins
o       Pediatric patients more likely to acquire subacute, rather than acute, bacterial endocarditis
o       Cardiac conditions where antibiotic prophylaxis recommended: prosthetic cardiac valves, previous infective endocarditis, congenital heart disease (unrepaired cyanotic congenital heart disease, repaired congenital heart defect with prosthetic material or device during the first 6 months after surgery, repaired congenital heart disease with residual defects at the site), cardiac transplantation recipients who develop cardiac valvulopathy
o       All dental procedures that involve manipulation of the gingival tissue, the periapical region of the teeth or perforation of the oral mucosa
o       Standard prophylaxis: 50mg/kg Amoxicillin 1 hour prior.
o       Allergy to penicillin:
§         20mg/kg Clindamycin 1 hour prior
§         50mg/kg Cephalexin/Cefadroxil 1 hour prior
§         15mg/kg Z-pac/Clarithromycin 1 hour prior
o       Unable to take oral meds: 50mg/kg Ampicillin IM or IV 30 min prior
o       Allergy to penicillin and unable to take oral meds:
§         20mg/kg Clindamycin IM or IV within 30 min of procedure
§         50mg/kg Cefazolin/Ceftriaxone IM or I within 30 min of procedure.

Wednesday, May 16, 2012

Record Keeping And Forms/Infection Control

RECORD KEEPING:
I. General Information and Principles
-informed consent, medical alerts, black ink for paper charts, individual charts, date of each visit, author for each note and time.
-Dental record: med hx, dental hx, clinical assessment, diagnosis, tx plan, progress notes
-Update med hx at each visit or diagnostic visit

II. Patient Info Section
-name, DOB, DOS, parent info, CC

III. Medical and Dental Hx
-Med hx- SMF, allergies, medications; a review of systems
-Dental hx- dental experience, OH status, date of last visit, radiographs, fluoride, habits, family dental hx

IV. Examination and Treatment Planning
-Occlusal relationship, overbite/jet, facial profile, midlines, crossbites, development, soft and hard tissue, dental pain, caries risk, behavior, tx plan, consults

V. Trauma Assessment
-Questions: how?, what?, where?, when?, fractures, pulp and alveolar bone health, mobility, sensitivity to percussion, palpation, temperature, soft tissue, mental status, prognosis, follow up

VI. Pharmacological/Behavior Guidance
-health status update, NPO recommendation, type and dose of sedation, local anesthesia, monitor vitals, informed consent, documentation, weight, time of sedation, time of dismissal, condition at discharge

VII. Preventative/Recall
-Determine recall status

VIII. Restorative
-teeth restored, surfaces, type of material, anesthetic, behavior

IX. Comprehensive Ortho
-pretreatment records, models, pan, ceph, diagnosis, tx plan

X. Consultation Request
-service requested for consult, patient IDs, specific questions, patient history, provider info, HIPPA release, special considerations such as urgency

XI. Informed Consent
-every patient has the right to be informed, should be rational, risks, benefits, document with signature, copy for the patient, of legal age, must be a parent or legal guardian, determine mental capacity, emergency care is an exception (Good Samaritan Laws), consent may need to be obtained for behavior management techniques

INFECTION CONTROL
I. Guidelines for Exposure Determination and Prevention- barrier protection
-assess health status (contagious), gloves, one handed scoop technique for recaping sharps and discard in sharps container, high speed should be sterilized, disinfect motor of slow speed, disposable air water syringe and suctions or sterilize, dental waterlines must contain < or equal to 500CFU/mL of bacteria, flush water lines for 20-30 secs after each patient


II. Protective Equipment
-hand hygiene between patients, gloves, fluid resistant gowns, and eye protection


III. Infection Control Categories of Patient Care Instruments
-Critical: surgical instruments or sharps that penetrate soft tissue
-Semi Critical: dull instruments that contact mucous membranes or nonintact skin
-Noncritical: extraoral instruments that contact the skin

IV. Method of Sterilization
-Sterilization- destroys all microorganisms
-High level disinfection- may not destroy spores
-Intermediate level of disinfection- destroys vegetative bacteria and majority of fungi and viruses
-Low level disinfection- may not destroy certain fungi and viruses

V. Major Methods and Sterilization
-Steam Autoclave: 121/250 C/F 15-20min
-Dry Heat Oven: 160/320 C/F 170/340 C/F 2/1hrs
-Rapid Heat Transfer: 375 F 12min wrapped and 6min unwrapped
-Unsaturated Chemical Vapor: 131/270 C/F 30min
-Ethylene Oxide: 25/75 C/F 10-16hrs

VI. Disinfection of Items
-Casts- chlorine or iodophors
-Impressions-chlorine or iodophors
-Prostheses- immerse in disinfectant
-Removable-chlorine compounds


Medical Emergencies

Resident: Swan
MEDICAL EMERGENCIES

I.
Preparation:  BLS, ALS (PALS)
Know the Emergency Meds:
1. Oxygen
-portable, capable of 100% O2 delivery for 30 minutes
-used for all medical emergencies
2. Epinephrine
-anaphylaxis
-acute asthma resistant to inhaled bronchodilator
-EpiPen (.3 mg), EpiPen Jr. (.15mg)  (for kids <40 lbs or under ~5)
3. Albuterol
-b2 Agonist, bronchodilator
-respiratory distress (not obstructive)
-acute asthma attack 
-Trade names: Proventil, Ventolin
4. Glucose
-for hypoglycemia
-tube of sugar (skittles, orange juice, etc)
-Glucagon (converts hepatic glycogen to glucose). Given IM
5. Diazepam, Midazolam
-Benzodiazepine (sedative, anticonvulsant, anxiolytic)
-Status epilepticus
6. Diphenhydramine (Benadryl)
-allergic reactions
-12.5 mg chewable tabs or liquid
-25 mg caps

II. PREVENTION 
-thorough medical histories, checked at each visit
-pt brings meds (ie MDI)
-refer, treat in hospital when appropriate
-reschedule if acute flare-up is likely
-reduce stress

III.  MANAGING EMERGENCIES-GENERAL PRINCIPLES
1. Stop tx and assess
2. Position patient
-if conscious, position of comfort
-if unconscious, place supine w/ legs elevated to increase cerebral blood flow
-if having a seizure, position to protect patient
3. Activate EMS
4.  ABCs of life support.  Apply AED if needed.
5. Give supplemental O2.
6 Calm, reassure, comfort
7. Monitor/record vital signs q5 min.


IV. COMMON EMERGENCIES  (P-Prevent, R-Recognize, M-Manage)
1. Syncope
P: reduce pain and anxiety, upright pt slowly, hypoglycemic pts have light meal pre-appointment
R: Vasovagal-fear, pain, anxiety.  Orthostatic-raising chair too quickly. Metabolic-hypoglycemis
Signs: nausea, pallor, diaphoresis. Tachycardia then bradycardia
M: position to increase cerebral bloodflow, supplemental O2, treat if hypoglycemic or in doubt.

2. Airway obstruction
P: titrate sedative drugs, monitor respiration, use proper positioning
R:  soft tissue-snoring, hypoxemia, cyanosis.  Foreign body-coughing, hypoxemia, chest retraction
M: Head tilt, chin lift, Heimlich for foregin body, supplemental O2 for s.t. obstruction

3. Hyperventilation
P: reduce pain/anxiety
R: rapid, shallow breathing, confusion, dizziness, numbness, tingling, cramping of hands and feet
M: Position patient. Calm, comfort, reassure. Have pt hold breath 10 sec at a time
-have patient breathe into O2 mask (or paper bag)

4. Acute Asthma
P: check history (frequency, duration, last attack, meds).  Don't use narcotics for mod-severe asthmatics. No Nitrous for severe asthmatics. 
-Have pt's meds ready, reappoint if needed
R: hyperactive airway can be triggered by allergy, exercise, stress, URI, irritants
-results in bronchospasm, edema, excess mucous secretion, wheezing on expiration
M: stop tx, calm/reassure pt.  Supplemental O2. 1-2 puffs albuterol inhaler (can repeat after 5 min)
-If severe, EpiPen

5.  CVA
R: weakness, confusion, dizziness, nausea, paralysis
M: Position, supp O2, rapid glucose test-treat hypoglycemia
EMS, check vital signs

6. Chest pain/Angina Pectoris
P: reduce pain/anxiety
R: hx of angina. Chest pain may radiate to anywhere above waist. Stress compounds problem of insufficient blood supply to myocardium
M: calm, comfort, reassure. Vitals.  Nitroglycerin .4 mg SL tab or spray (can repeat q 5 min up to 3 times)
If no relief after 3 doses, assume MI. Call EMS

7. Cardia arrest
R: unconscious, no pulse
M: BLS, supplemental O2. AED, defibrillate if indicated

8. Allergic reactions
P. Identify Patients with documented allergies!!!
R:  pruritis/urticaria, dyspnea, wheezing, pallor, cyanosis
M: Stop tx, supp O2, Vitals.
-Benadryl 25-50 mg PO
-if anaphylactic, Epi 1:1000 IM. Repeat every 5-10 as needed.

9. Seizures
P: Med hx (frequency, last seizure, meds taken.
-avoid medication overdose. Reduce stress
R: transient alteration of consciousness, behavior
-TonicClonic:  Prodromal phase (30% have aura)
-Ictal phase: tonic contractions followed by clonic movements
-post ictal phase: (most dangerous phase) unconsciousness leading to confused awakening
M: position, prevent injury.
-BLS, supp O2.
-Status Epilepticus: Diazepam .3 mg/kg to 10 mg max

10. Hypoglycemia
P: light food prior to appt
R: palpitations, diaphoresis, confusion-unconsciousness
-rapid glucose test (serum glucose <50 mg/100mL)
M: Stop, position, BLS, supp O2.
If conscious, sugar PO
If unconscious, glucagon 1 mg IM
EMS!





Allergic & Immune Disorders

Resident’s Name:   Jessica Wilson                                   Program:  Lutheran Medical Center - Providence

AAPD Handbook of Pediatric Dentistry: Allergic & Immune Disorders

Anaphylaxis:
-Overwhelming immediate systemic reaction due to an IgE mediated release of mediators from tissue mast cells and peripheral blood basophils that occurs rapidly and can be fatal.
Tx:
-few hives and nausea- 1-2 mg/kg diphenhydramine q6h for 24h
-widespread hives, angioedema, tongue/lip, cough, wheeze, vomiting, diarrhea- monitor vitals q15min, 0.01 mg/kg IM epi q15min x 2 doses, 1-2 mg/kg IM or IV diphenhydramine, call 911 if life-threatening reactions or LOC occurs.
Allergic Rhinitis:
-Inflammation of nasal mucous membranes resulting from an IgE-mediated allergic rxn to the protein/glycoprotein of inhaled aeroallergens
Tx: intranasal corticosteroids, antihistamines, decongestants
Dental considerations: in severe cases mouth breathing may predispose to ortho problems (if mouth breathing and no dx, dentist should refer to allergist), nasal airway obstruction may be a concern for sedation dentistry
Atopic Dermatitis:
-Chronic dermatitis characterized by pruritis and relapsing inflammation. Affects infants and young children along extensor surfaces, cheeks, forehead and neck, older children and adults in flexural areas.
Urticaria & Angioedema:
-Urticaria- extremely pruritic, erythematous, raised lesions affecting the superficial dermis layers that blanch with pressure
-Angioedema- similar to urticaria, but swelling is deeper and primarily affects face, extremeties, genetalia and occasionally the tongue.
Tx: Antihistamines and oral steriods
Hereditary Angioedema:
-AD disorder resulting from a deficiency in functional C1 esteraseinhibitor. Edema may be triggered by trauma, medical or dental procedures, emotional stress, menstruation, infections, medications.
Tx: daily prophylactic anabolic attenuated adrogens. NOTE: Epi and antihistamines not useful in managing edema.
Food Allergy:
-Immune response induced by exposure to a particular food protein. May be IgE mediated, cell-mediated or both. Most children outgrowtheir allergies by age 5 with the exceptions of peanuts, tree nuts, fish and shellfish. These patients should carry an epi-pen at all times.
Latex Allergy:
-May present as Irritant contact dermatitis(non-immunologic, 80% of hand dermatitis), allergic contact dermatitis ( delayed hypersensitivity, T cell mediated response), or immediate allergic reaction (IgE mediated).
Asthma:
-Asthma is the most common chronic medical condition of childhood. It is most common in African Americans and urban dwellers, particularly those of lower SES.
-Dx: use of spirometry (>6yo) or peak flow measurements (>4yo).
Dental Considerations: These patients may experience increased prevalence of caries and tooth wear, oral candidiasis, decreased salivary flow rates and gingivitis from mouth breathing.
Juvenile Arthritis:
-Can be divided into systemic arthritis, pauciarthritis (<5 joints), polyarthritis, and psoriatic arthritis.
-Dental considerations: patients usually in chronic pain with overprotective parents, may have limited movement including the cervical area and TMJ. They may have difficulty cleaning their teeth if hands or arms involved.
Vasculitides in Children:
-Wegener Granulomatosis- systemic vasculitis including nasal or oral inflammation, ulcers, bloody discharge and subglottic stenosis. Extremely rare in children.
-Bechet’s Disease- apthous ulcers, often extensive and multiple, genital ulceration, cutaneous lesions, ocular disease. Very rare in children.
Systemic Lupus Erythematosus:
-Chronic inflammatory disorder of unknown cause, rare in childhood.
_Dental considerations: increased susceptibility of infection, may require antibiotic prophylaxis for secondary heart damage, xerostomia.
Congenital and Acquired Immunodeficiencies:
-Dental considerations: Aggressive prevention, may need CBC, white cell differential and platelets prior to any invasive dental procedure, extract pulpally involved teeth to prevent septicemia.