Presentation on theme: "Medical Issues and Reverse Medical Histories"— Presentation transcript:
1Medical Issues and Reverse Medical Histories JOE ALAMAT DDS, MDSUMMIT ORAL AND MAXILLOFACIAL SURGERY(586) )
2Medication ListLearn to decipher the patient’s medical history through medication lists.Know why they are on the medicationsWhat precautions should be takenLearn to think like the PCP.
3Topics that will be covered CVSDiabetesImmunocompromisedPregnancyOral CancerOsteoporosis
4Cardiovascular diseases Two disease entities will be covered:HypertensionMyocardial infarction
5Traditional 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
7HTN 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
8Complications of HTNThe problems associated with HTN or increased afterloadHeart has to pump with more force to overcome the pressureCardiac hypertrophy and eventually left ventricular dysfunction developsEnd organ damage (fundoscopic, renal, brain) all associated with vascular damage
9How can we decrease the pressure in this closed systemDecrease pump strengthIncrease the volume in arteriesIncrease volume in the veinsDecrease fluid in the system
10Medications To Treat HTN Beta blockers (olols) decrease pump strength and speedDiuretics (Lasix, Lozol, HCTZ) decrease fluid in the systemAce inhibitors (prils) decrease the fluid resorption in the kidneys and prevents angiotensin from developing
11Medications To Treat HTN Calcium channel blockers (norvasc etc) increase the volume in the arteriesARBs block the vasoconstrictive effects of angiotensinAlpha antagonists (Terazosin) relax arteries and increase the volume of the arteriesCentrally acting (Clonidine) decrease sympathetic outflow on the CVS
12Mild HTN easily controlled based on prescription
13Moderate to Severe Hypertension based on prescription
14How would you address a clearance The more meds a patient is on to control HTN, the more labile the HTNAvoid excessive epiMeasure the BPAspirate when injectingCalm environment
16MIYou 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.
17Mi ManagementDecrease the preload ( blood return to heart) with nitrates like nitrodur
18MI ManagementDecrease the afterload (so the heart is not pumping against high pressure so as not to stress the heart) BP medsARBAce inhibitorBeta blockeretc
19Mi ManagementIncrease blood flow to the myocardium by using nitrates
20Mi ManagementImprove the lipid profile by using statins
21Lipid profile drugs Cholesterol lowering medications Lipitor (went generic)ZocorThey are both statins decrease production of cholesterolZetia decreases absorptionZocor and Zetia called VytorinOthers are Crestor and Niaspan and Tricor
22Mi ManagementAnticoagulate to prevent reocclusion of the stent and dissolve or prevent thrombotic emboli .(antiplatelets)AspirinPlavix
23AnticoagulantCoumadin inhibits factors 10, 9, 7 and 2 from forming in the liver. Half life 20-60hoursPradaxa (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.
24ADA 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.
26MI managementRegulate the speed of the heart so that arrhythmias do not develop.
27Beta Blockers Used to treat HTN, angina and Migraines Work on the beta receptors and block them, unlike asthma medications that stimulate the receptorsMetoprolol (Lopressor) is a cardioselective med
28MI managementAmiodarone for ventricular tachycardia
29Red FlagsCoumadin s/p MI indicates significant ventricular dysfunction secondary to ischemia.Amiodarone suggests that the patient has a history of dangerous ventricular tachycardia and rhythm
30Dental clearanceIncreased risk of problems in the first 6 months status post MIDo Not stop Plavix or aspirin or coumadinNo epiNo NsaidsAsk if patient gets shortness of breath.(Functional Capacity)
31Diabetes Random glucose above 200 Type I autoimmune Fasting Glucose99 or below is normal100 to 125 Pre-diabetes impaired fasting glucose126 or above diabetes*Random glucose above 200Type I autoimmuneType two insulin resistance
32Metabolic SyndromeThe 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
33Metabolic SyndromeSome 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.
35Diagnosis 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/dLReduced HDL (“good”) cholesterol: Men — Less than 40 mg/dL Women — Less than 50 mg/dLElevated blood pressure: Equal to or greater than 130/85 mm HgElevated fasting glucose: Equal to or greater than 100 mg/dL
36Manifestations of Metabolic Syndrome Skin TagsAcanthosis Nigrans
37Type of ObesityCentral AdiposityGeneralized adiposity
39Treatment of diabetes Oral Hypoglycemic Insulin if resistant or level highWeight modificationACE inhibitors if protein is in the urine to protect the kidneysUsually associated with hypertriglyceridemiaUsually treated with Niaspan
40Functional Medicine In addition to Medications, supplements are used. ZincChromiumALAVit D (sequestered in fat)CoQ10Omega 3SleepDecrease stress levelsLow Glycemic Index foods
41Glycemic IndexIt measures how fast food raises the sugar level in the bloodGlucose has a GI of 100. shoot for foods less than 55E.g.Bagel 72Cornflakes Coco Pops 73Rice Cakes Pretzels 83Ice cream 57Apple 39Fruit roll Ups M&& peanut 33
42Dental clearance issues Minimize NSAIDsWatch for hypoglycemiaWatch carefully for infections( use cidal meds such as PCN Doc)Ask about their HBA1C
43Immunocompromised patients Patients that fall in this category are numerous. Among them arethose on steroids over 20 of prednisone daily.Organ transplant patientsPatients on chemotherapyPatients taking DMARDS( disease modifying anti rheumatic drugs)
45Transplant Patients Liver Kidney Heart function is assessed by the PT which measures Ask about increased bleeding, bilirubin etc. If tests are okay then treat as an immunocompromised patientKidneyask about the bun and creatinin. Should be 10, and 1 respectively. If tests okay treat as immunocompromised patientHeartAsk about EF and CHF.
46Transplant Patients Some of their meds include: Azathioprine Cellcept avoid motrinCyclosporine avoid emycin, motrinImmuranPrograf avoid emycin, motrinGVHD lichenoid reactions
47DMARDSAre 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)
48What are the “MABS” They are drugs that are Monoclonal AntiBodies. They are from animalsRats- AMABHamster-EMABPrimate- IMABMouse- OMABHuman-UMABFrom human and animal mixed thus they are called chimericXIMAB (Constant part is human)ZUMAB (variable is human)They are used in Cancer treatment, autoimmune disease, osteoporosis, and many other uses.
49Immunocompromised patients Beware of infections consider premedicationBe aware of transient bacteremia from poor oral hygieneDo not give NSAIDSDo not give erythromycin or Z packsDOC is tylenol or UltramPen vk is DOCClinadamycin if that doesn’t work
50Pregnancy Not a contraindication to treatment. Important points are pen vk, clindamycin are allowedTylenol3, tylenol, vicodin are all permittedAbsolutely no NSAIDS or steroids.Steroids are teratogenicNSAIDS shut down the ductus arterosis.Minimize epi.That is what is in a clearance.
51Cancer PatientsPrior to undergoing chemo treat any potential source of infection. Be aggressiveDuring chemo therapy treat only emergencies. They are at high risk of fulminant infections and surgery sites heal very slowlyUse cidal antibiotics such as penicillin as first therapyArimidex or tamoxifen are used for ongoing breast CA treatmentLeupron for prostate CA
52Cancer PatientsExtract any tooth that is in the line of the beam if radiation therapy is to be done always at a risk for ORNFluoride trays must be madeCleanings and exam every three months.Note about HPV (Cetiximab or Erbitux)
53OsteoporosisIn 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
56BisphosphonatesAt 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
57Bisphosphonates Actonel (risedronate) PO Aredia (pamidronate) IV Boniva (ibandronate) IVFosamax (alendronate)Reclast (zolendronate) once a year for osteoporosis IVSkelid (tiludronate) POZometa (zolendronate) Once a month for cancer IV
58Osteoporosis drug may reduce colon cancer risk Mayo clinic health letter 2011 Jul;29(7):4.
59Oral 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 Oct;36(8): doi: /apt Epub 2012 Sep 11.
60Bisphosphonate 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
61Prolia (Denusomab)Prolia( denosumab)fully human monoclonal antibody denosumab inhibits osteoclast development, function, and survivalInhibits the RANKL protein that acts as the primary signal for bone removal
62SERMSViviant(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
63Forteo 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
64Tylenol VS NSAIDs which is better They both work wellBut avoid NSAIDs in older patients due to kidney and GI concerns.Avoid in diabetics and renal patients.Contraindicated in pregnancy
65RED FLAGS Shortness of breath BP above 200/100 Wheezing that doesn’t resolve after two puffs of albuterolCirrhosis patientsPatients on amiodarone do not give epiTransplant patients do not give motrin or erythromycin
66Red FlagsMI in the last 6 monthsPregnant patients are not red flags