medical issues for dental procedures

Systemic diseases for dental procedures

นายแพทย�เอลวิ�ล เพชรปล�กอาย�รแพทย�เฉพาะทางระบบทาง

เดิ�นอาหาร16/9/2010

Topics

• Antiplatelet and Anticoagulant therapy in dental procedures

• Hypertension in dental procedures• Diabetes in dental procedures• Steroid treatment patient in dental procedures• Chronic liver diseases in dental procedures

Antiplatelet

Antiplatelet and Anticoagulant in dental procedures

• Antiplatelet Therapy for Prevention of Ischemic Cardiovascular Events and Stent Thrombosis

• Management of Oral Anticoagulant Therapy

Antiplatelet Therapy for Preventionof Ischemic Cardiovascular Events and

Stent Thrombosis

• 1 month after bare-metal stent implantation patients should be treated with clopidogrel 75 mg and aspirin 325 mg

• 3 months after sirolimus drug eluting stent (DES) implantation

• 6 months after paclitaxel DES implantation and ideally, up to 12 months if they are not at high risk for bleeding

Recommendations for the prevention of stent thrombosis after coronary stent implantation , at a minimum

Circulation. 2007;115:813-818.

Recommendations for the prevention of stent thrombosis after coronary stent implantation , at a minimum

• Stent thrombosis most commonly occurs in the first month after stent implantation

• In patients treated with DES, stent thrombosis occurred in 29% of whom antiplatelet therapy was discontinued prematurely

Circulation. 2007;115:813-818.

Antiplatelet in dental procedures

• prospective study of single tooth extractions on patients randomized to aspirin versus a placebo failed to show a statistically significant difference in postoperative bleeding

• no well-documented cases of clinically significant bleeding after dental procedures, including multiple dental extractions

Circulation. 2007;115:813-818.

• Clopidogrel was combined with aspirin and administered for prolonged duration (up to 28 months), an absolute increase (ranging from 0.4% to 1.0%) in major bleeding, compared with aspirin alone

• Many procedures (eg, minor surgery, teeth cleaning, and tooth extraction) can likely be performed at no or only minor risk of bleeding or could be delayed until the prescribed antiplatelet regimen is completed

Antiplatelet in dental procedures

Circulation. 2007;115:813-818.

Antiplatelet in dental proceduresconclusion

Unlikely occurrence of bleeding once an initial clot has formed.

With local measures during surgery (eg, absorbable gelatin sponge and sutures), there is

little or no indication to interrupt antiplatelet drugs for dental procedures.

Circulation. 2007;115:813-818.

Ischemic Heart Disease: DentalManagement Considerations

Patient with stable angina can usually undergo routine dental care safely

Patient with unstable angina is considered danger for dental procedures, angina is considered unstable if it

is changing for the worse in some parameterAngina is now occurring more frequently

Angina appears at lower levels of exertion than in the past

Angina requires larger doses of nitrates for relief

Angina relief takes longer than in prior episodes

Ischemic Heart Disease: DentalManagement Considerations

In the past, myocardial infarctions, limit noncardiac surgical interventions on these patients for at least 6 months.

Nowadays, early and rapid interventions, myocardial damage can be minimal, no reason to delay even elective dental procedures.

Dent Clin N Am 50 (2006) 483–491

Anticoagulant

Anticoagulant in dental procedures

Clotting Cascade

Vitamin K

Synthesis of Functional

Coagulation Factors

VII

IX

X

II

Vitamin K-Dependent Clotting Factors

Warfarin

Synthesis of Non

Functional Coagulation

Factors

Antagonismof

Vitamin K

Warfarin Mechanism of Action

Vitamin K

VII

IX

X

II

Anticoagulant in dental procedures

• Prophylaxis and/or treatment of:–Venous thrombosis and its

extension–Pulmonary embolism–Thromboembolic complications

associated with AF and cardiac valve replacement

• Post MI, to reduce the risk of death, recurrent MI, and thromboembolic events such as stroke or systemic embolization

• Prevention and treatment of cardiac embolism

Warfarin: Indications

Antithrombotic Agents: Mechanism of Action

Anticoagulants: prevent clot formation and extension Antiplatelet drugs: interfere with platelet activity Thrombolytic agents: dissolve existing thrombi

( )Patient’s PT in SecondsMean Normal PT in Seconds

INR =ISI

INR = International Normalized Ratio ISI = International Sensitivity Index

INR Equation

MeanNormal(Seconds)

PTR ISI INR

12

12

13

11

14.5

1.3

1.5

1.6

2.2

2.6

A

B

C

D

E

Blood from a single patient

Patient’sPT

(Seconds)

16

18

21

24

38

ThromboplastinReagent

How Different Thromboplastins Influence the PT Ratio and INR

MeanNormal(Seconds)

PTR ISI INR

12

12

13

11

14.5

1.3

1.5

1.6

2.2

2.6

3.2

2.4

2.0

1.2

1.0

2.6

2.6

2.6

2.6

2.6

A

B

C

D

E

Blood from a single patient

Patient’sPT

(Seconds)

16

18

21

24

38

Thromboplastinreagent

How Different Thromboplastins Influence the PT Ratio and INR

J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687 983.

INR: International Normalized Ratio

A mathematical “correction” (of the PT ratio) for differences in the sensitivity of thromboplastin reagents

Relies upon “reference” thromboplastins with known sensitivity to antithrombotic effects of oral anticoagulants

INR is the PT ratio one would have obtained if the “reference” thromboplastin had been used

Allows for comparison of results between labs and standardizes reporting of the prothrombin time

Skin bleeding time

Technical variability: Despite attempts at standardization, the test remains poorly reproducible and subject to a large number of variables.

Technique-related factors include location and direction of the incision

The skin bleeding time does not necessarily reflect bleeding from any other site.

The bleeding time may be within the normal range in VWD, and in aspirin users

British Journal of Haematology, 2008, 140, 496–504

Guidelines for the management of patients on oral anticoagulants requiring dental surgery

Summary of key recommendations1. The risk of significant bleeding in patients

on oral anticoagulants and with a stable INR in the therapeutic range 2-4 (i.e. <4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extraction (grade A level Ib).

British Committee for Standards in Haematology 2007


Summary of key recommendations2. Recommendations: For patients stably

anticoagulated on warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their anticoagulant regimen (grade C, level IV).



Summary of key recommendations3. The risk of bleeding may be minimised by: a. The use of oxidised cellulose (Surgicel)

or collagen sponges and sutures (grade B, level IIb).

b. 5% tranexamic acid mouthwashes used four times a day for 2 days (grade A, level Ib).

4. For patients who are stably anticoagulated on warfarin, a check INR is recommended 72 hours prior to dental surgery (grade A, level Ib)


Best evidence statement (BESt). Management of warfarin therapy

It is recommended, for patients undergoing dental extractions, consider use of tranexamic mouthwash or epsilon aminocaproic acid mouthwash without interruption of anticoagulation therapy

CHEST 2008 Anticoagulation Guidelines

The risk of thrombosis associated with temporarily discontinuing anticoagulants prior to dental surgery is small but potentially fatal.

In the review of Wahl, 5/493 (1%) patients undergoing 542 dental procedures and in whom anticoagulants were withdrawn specifically for surgery, had serious embolic complications of which 4 were fatal

The risk of thrombosis if anticoagulants are discontinued

Arch Intern Med 1998;158(15):1610-6.

Metanalysis, comprising 2014 dental surgical procedures in 774 patients receiving continuous warfarin therapy, undergoing single, multiple extractions and full mouth extractions , included patients with an INR up to 4.0, more that 98% of patients receiving continuous anticoagulants had no serious bleeding problems.

Twelve patients (<2%) had postoperative bleeding problems that were not controlled by local measures.

Major bleeding was rare (4/2012, 0.2%) for patients with a therapeutic INR (<4) undergoing dental surgery.

The risk of major bleeding in patients undergoing oral surgery if anticoagulants are continued

Arch Intern Med 1998;158(15):1610-6.

Blood pressure in HT

Dental Management of Patientswith Hypertension

The seventh revision by the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure and is known as the JNC-7 Report

Above which BP values should the dentist not treat?

Many well-respected authors have published 180/110 for the absolute cutoff for any dental treatment

In fact, this value may be too high for patients who have had previous hypertensive-related organ damage, such as myocardial infarctions, strokes, or labile angina.

Conversely, healthy patient with a negative medical history with values around 200/110 may be treated without any perioperative complications.

Dent Clin N Am 50 (2006) 547–562

‘‘Risk assessment’’

Physical classification system of the American Society of Anesthesiologists (ASA) has been in use since 1941.

The higher the ASA class, the more at-risk the patient is both from a surgical and anesthetic perspective [31]. ASA Class I. A normal healthy

patient ASA Class II. A patient with mild

systemic disease ASA Class III. A patient with

severe systemic disease ASA Class IV. A moribund patient

who is not expected to survive without the operation

Key in determining the likelihood of complications


Metabolic equivalent or METS, one MET is defined as 3.5 mL of 02/Kg/min

It essentially is a test of the patient’s ability to perform physical work. 1 to 4 METS: eating, dressing,

walking around house, dishwashing 4 to 10 METS: climbing at least

one flight of stairs, walking level ground 6.4 km/hr, running short distance, game of golf

>=10 METS: swimming, singles tennis, football Dent Clin N Am 50 (2006) 547–562


People with capacities of 4 METS or less are at high risk for medical complications.

Those who can perform 10 METS or more are at very low risk. Example; a person who is anxious

with a BP 200/115 but can perform 10 METS of work would likely have no problems with a simple extraction.

Dent Clin N Am 50 (2006) 547–562

Algorithm for treating the hypertensive dental patient.

The algorithm assumes no other medical contraindications such as a recent stroke, unstable dysrhythmias, myocardial infarction, or pregnancy.Dent Clin N Am 50 (2006) 547–562

Blood sugar and DM

Dental Management of Patientswith Diabetes

Normal plasma glucose : FPG < 100mg/dL Diagnosis of DM is the patient who

presents with classic symptoms of polyuria, thirst, weight loss, fatigue, visual blurring, and a FPG >126 mg/dL, or a random value of at least 200 mg/dL.

American Diabetic Association (ADA)

Dental Management of Patients with Diabetes

In the absence of these classic symptoms, glucose intolerance may exist as impaired fasting glucose (IFG) when the FPG is between 100 and 125 mg/dL.

Plasma glucose of 140 to 199 mg/dL following OGTT defines impaired glucose tolerance (IGT).

The classification of IFG and IGT is important because individuals with IFG and IGT are at greater risk of developing diabetes and atherosclerotic cardiovascular disease even if they do not develop DM

American Diabetic Association (ADA)

Glucose Control Study Summary

The intensive glucose control policy maintained a lower HbA1c by mean 0.9 % over a median follow up of 10 years from diagnosis of type 2 diabetes with reduction in risk of:

12% for any diabetes related endpointp=0.029

25% for microvascular endpoints p<0.0116% for myocardial infarctionp=0.052

24% for cataract extraction p=0.046

21% for retinopathy at twelve yearsp=0.015

33% for albuminuria at twelve yearsp<0.001

UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.

Conclusion

The UKPDS has shown that

intensive blood glucose control

reduces the risk of diabetic

complications, the greatest effect

being on microvascular

complicationsUK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.

Dental consideration in DM patient

Aspirin Therapy (for adults) – 75-162 mg/day as primary and secondary prevention of cardiovascular disease unless contraindicated.

Systemic complications from DM hypertension cardiodiovascular disease renal insufficiency

Basic guidelines for diabetes care. California Diabetes Program; 2008.

Performing dental procedures on diabetic patients

Main concern is to avoid acute incidents hyper or hypo-glycemic comas

during the operation to secure a smooth post-operational course (wound healing

and infection)

Above which blood sugar level should the dentist not treat?

No absolute cutoff value for any dental treatment (generally acceptable value of 100-200mg/dl in elective minor procedures without NPO)

In fact, any level of blood sugar should be treated for abscess which need drainage procedures, may be in case of periodontitis with poor glycemic control

In well-controlled diabetes, probably no greater risk of postoperative infection than is the nondiabetic

When surgery is necessary in the poorly controlled diabetic (random blood sugar >200mg/dl), prophylactic antibiotics should be considered

Periodontal Treatment on Glycemic Control of Diabetic Patients

Meta-analysis suggests that periodontal treatment leads to an improvement of glycemic control in type 2 diabetic patients for at least 3 months (periodontal therapy is favorable and can reduce A1C levels on average by 0.40% more than in nonintervention control subjects)

Diabetes Care. 2010; 33; 421-427

Steroid

Steroid treatment patient in dental procedures

Secondary adrenocortical insufficiency (AI) results from the administration of exogenous corticosteroids

In secondary AI, normal mineralocorticoid function is preserved and less likely for patients to experience adrenal crisis than it is for patients with primary AI.

Long term steroid treatment in medicine

Autoimmune disease; SLE, AIHA, ITP, RA, vasculitis syndromes, nephrotic-nephritis syndromes, AIH, IBD, autoimmune pancreatitis, etc.

Allergic diseases; asthma Post organ transplantation Adrenal insufficiency; primary or secondary

Steroid treatment in dental procedures

Adrenal crisis, event can occur when a patient with AI ( most commonly in the form of Addison’s disease), is challenged by stress (for example, illness, infection or surgery), and, in response, is unable to synthesize adequate amounts of cortisol and aldosterone.

Adrenal crisis is rare in patients with secondary AI, because the majority of these patients have normal aldosterone levels

Steroid treatment in surgical procedures

Risk of adrenal crisis appears to be low in minor surgery

Majority of patients who regularly take the daily equivalent dose of steroid (5-10 mg of prednisone daily) maintain adrenal function and do not require supplementation for minor surgical procedures Minor surgical stress the glucocorticoid

target is about 25 mg of hydrocortisone equivalent on the day of surgery

Moderate surgical stress the glucocorticoid target is about 50-75 mg/day of hydrocortisone equivalent for 1-2 days

Major surgical stress the glucocorticoid target is 100-150 mg/day of hydrocortisone equivalent for 2-3 days

Who is at risk of experiencing adrenal crisis during dental procedures?

Adrenal crisis is rare in dentistry

J Am Dent Assoc 2001;132;1570-1579

Patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids so long as they continue to receive their usual daily dose of corticosteroid. Arch Surg. 2008;143(12):1222-1226


In patients who receive physiologic replacement doses of corticosteroids, these patients are unable to increase endogenous cortisol production in the face of stress

These patients require adjustment of their glucocorticoid dose during surgical stress under all circumstances.

Arch Surg. 2008;143(12):1222-1226


J Am Dent Assoc 2001;132;1570-1579

Cirrhosis

Chronic liver diseases in dental procedures

Potential for impaired hemostasis and bleeding diathesis due to thrombocytopenia or reduced hepatic synthesis of coagulation factors

Increased risk of infection, or spread of infection

Chronic liver diseases in dental procedures

If any significantly abnormal result in platelet count, PT or INR is detected in a patient with cirrhosis, medical consultation is recommended

Currently, no evidence-based data to support the recommendation that patients with cirrhosis should have antibiotic prophylaxis before routine dental procedures.

medical issues for dental procedures

Documents