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JOE ALAMAT DDS, MD SUMMIT ORAL AND MAXILLOFACIAL SURGERY (586)703-7104)

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Presentation on theme: "JOE ALAMAT DDS, MD SUMMIT ORAL AND MAXILLOFACIAL SURGERY (586)703-7104)"— Presentation transcript:

1 JOE ALAMAT DDS, MD SUMMIT ORAL AND MAXILLOFACIAL SURGERY (586) )

2 Medication List Learn to decipher the patient’s medical history through medication lists. Know why they are on the medications What precautions should be taken Learn to think like the PCP.

3 Topics that will be covered CVS Diabetes Immunocompromised Pregnancy Oral Cancer Osteoporosis

4 Cardiovascular diseases Two disease entities will be covered: Hypertension Myocardial infarction

5 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

6 Preload Afterload Ejection fraction

7 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

8 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

9 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

10 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

11 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

12 Mild HTN easily controlled based on prescription

13 Moderate to Severe Hypertension based on prescription

14 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

15 Always Check the BP

16 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.

17 Mi Management Decrease the preload ( blood return to heart) with nitrates like nitrodur

18 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

19 Mi Management Increase blood flow to the myocardium by using nitrates

20 Mi Management Improve the lipid profile by using statins

21 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

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

23 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 hours. No INR required. Xarelto (rivaroxaban) is a factor Xa inhibitor. Half life 5-9 hours.

24 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.

25 Never stop Plavix or ASA after a recent MI

26 MI management Regulate the speed of the heart so that arrhythmias do not develop.

27 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

28 MI management Amiodarone for ventricular tachycardia

29 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

30 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)

31 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

32 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 can’t use insulin efficiently. This is why the metabolic syndrome is also called the insulin resistance syndrome

33 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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35 Diagnosis is three or more Elevated waist circumference: Men — Equal to or greater than 40 inches (102 cm) Women — Equal to or greater than 35 inches (88 cm) Elevated triglycerides: Equal to or greater than 150 mg/dL Reduced HDL (“good”) cholesterol: Men — Less than 40 mg/dL Women — Less than 50 mg/dL Elevated blood pressure: Equal to or greater than 130/85 mm Hg Elevated fasting glucose: Equal to or greater than 100 mg/dL

36 Manifestations of Metabolic Syndrome Skin Tags Acanthosis Nigrans

37 Type of Obesity Central AdiposityGeneralized adiposity

38 Diabetes meds Actos, Avandia Decreases insulin resistance Lantus Long acting injected insulin Byetta Increases insulin secretion Metformin Decreases absorption

39 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

40 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

41 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

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

43 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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45 Transplant Patients Liver function is assessed by the PT which measures 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.

46 Transplant Patients Some of their meds include: Azathioprine Cellcept avoid motrin Cyclosporine avoid emycin, motrin Immuran Prograf avoid emycin, motrin GVHD lichenoid reactions

47 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)

48 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.

49 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 doesn’t work

50 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.

51 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

52 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)

53 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

54 Calcium Metabolism

55 Osteoporosis Medications

56 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 agency’s analysis, which found little if any benefit from the drugs after three to five years of use

57 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

58 Osteoporosis drug may reduce colon cancer risk Mayo clinic health letter 2011 Jul;29(7):4.

59 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 Oct;36(8): doi: /apt Epub 2012 Sep 11.

60 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 28;18(40): doi: /wjg.v18.i

61 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

62 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

63 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

64 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

65 RED FLAGS Shortness of breath BP above 200/100 Wheezing that doesn’t resolve after two puffs of albuterol Cirrhosis patients Patients on amiodarone do not give epi Transplant patients do not give motrin or erythromycin

66 Red Flags MI in the last 6 months Pregnant patients are not red flags


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