Medical Issues and Reverse Medical Histories

1. Medical Issues and Reverse Medical Histories JOE ALAMAT DDS, MD SUMMIT ORAL AND MAXILLOFACIAL SURGERY dralamat@yahoo.com (586)703-7104)

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 12-17 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.

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/dLWomen — 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 Adiposity Generalized 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)

45. 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.

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.